Provider Demographics
NPI:1104215177
Name:GOOCH, KIEFER (PT)
Entity Type:Individual
Prefix:
First Name:KIEFER
Middle Name:
Last Name:GOOCH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 S QUEEN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3506
Mailing Address - Country:US
Mailing Address - Phone:302-724-6344
Mailing Address - Fax:302-449-2047
Practice Address - Street 1:642 S QUEEN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3506
Practice Address - Country:US
Practice Address - Phone:302-724-6344
Practice Address - Fax:302-449-2047
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003263225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist