Provider Demographics
NPI:1295509867
Name:GOUGH, SOPHIA LASIE
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:LASIE
Last Name:GOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1259 LIMIT AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-1748
Mailing Address - Country:US
Mailing Address - Phone:443-510-8226
Mailing Address - Fax:
Practice Address - Street 1:1259 LIMIT AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-1748
Practice Address - Country:US
Practice Address - Phone:443-510-8226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator