Provider Demographics
NPI:1043812969
Name:GOUGH, LESLIE B
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:B
Last Name:GOUGH
Suffix:
Gender:M
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 434
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:WV
Mailing Address - Zip Code:26034-0434
Mailing Address - Country:US
Mailing Address - Phone:304-479-5144
Mailing Address - Fax:
Practice Address - Street 1:256 ALBA AVE
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:WV
Practice Address - Zip Code:26034-1559
Practice Address - Country:US
Practice Address - Phone:304-479-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator