Provider Demographics
NPI:1093094013
Name:GOHEEN, TERRY LEE II (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LEE
Last Name:GOHEEN
Suffix:II
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15874 MEDORA ST
Mailing Address - Street 2:
Mailing Address - City:DOW
Mailing Address - State:IL
Mailing Address - Zip Code:62022-3173
Mailing Address - Country:US
Mailing Address - Phone:618-885-5602
Mailing Address - Fax:
Practice Address - Street 1:15874 MEDORA ST
Practice Address - Street 2:
Practice Address - City:DOW
Practice Address - State:IL
Practice Address - Zip Code:62022-3173
Practice Address - Country:US
Practice Address - Phone:618-885-5602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003047224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant