Provider Demographics
NPI:1689401622
Name:GOOCH, JEREMIAH ANTHONY (RBT)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:ANTHONY
Last Name:GOOCH
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 HERITAGE CT APT 101
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-2246
Mailing Address - Country:US
Mailing Address - Phone:214-529-6207
Mailing Address - Fax:
Practice Address - Street 1:3100 HERITAGE CT APT 101
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-2246
Practice Address - Country:US
Practice Address - Phone:214-529-6207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician