Provider Demographics
NPI:1811513195
Name:GOUGE, ELISABETH JOY
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:JOY
Last Name:GOUGE
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:PO BOX 4169
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-8169
Mailing Address - Country:US
Mailing Address - Phone:503-371-4160
Mailing Address - Fax:503-375-9727
Practice Address - Street 1:2586 12TH PL SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2536
Practice Address - Country:US
Practice Address - Phone:503-371-4160
Practice Address - Fax:503-375-9727
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)