Provider Demographics
NPI:1457085037
Name:GOUGH, TIM DUANE JR (LCSW-C)
Entity type:Individual
Prefix:MR
First Name:TIM
Middle Name:DUANE
Last Name:GOUGH
Suffix:JR
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E CECIL AVE STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-4057
Mailing Address - Country:US
Mailing Address - Phone:667-231-1269
Mailing Address - Fax:
Practice Address - Street 1:102 E CECIL AVE STE B
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-4057
Practice Address - Country:US
Practice Address - Phone:667-231-1269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD287451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical