Provider Demographics
NPI:1871609990
Name:GOCH, AMY ELLEN (PHD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELLEN
Last Name:GOCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 MEDLOCK RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1515
Mailing Address - Country:US
Mailing Address - Phone:404-378-1210
Mailing Address - Fax:404-378-7414
Practice Address - Street 1:544 MEDLOCK RD
Practice Address - Street 2:SUITE 104
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1515
Practice Address - Country:US
Practice Address - Phone:404-378-1210
Practice Address - Fax:404-378-7414
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1007103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBDRLMedicare ID - Type Unspecified