Provider Demographics
NPI:1295161743
Name:GAUGH, AMY I (LCSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:I
Last Name:GAUGH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5242 S 4820 W
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-6422
Mailing Address - Country:US
Mailing Address - Phone:801-966-4251
Mailing Address - Fax:801-966-4289
Practice Address - Street 1:5242 S 4820 W
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-6422
Practice Address - Country:US
Practice Address - Phone:801-966-4251
Practice Address - Fax:801-966-4289
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
UT9039386-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker