Provider Demographics
NPI:1154636546
Name:GOSS, SHIRLEY ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANN
Last Name:GOSS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6108 S LOS LAGOS CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-7005
Mailing Address - Country:US
Mailing Address - Phone:575-494-7278
Mailing Address - Fax:
Practice Address - Street 1:6701 W UNION HILLS DR STE 2
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8067
Practice Address - Country:US
Practice Address - Phone:575-494-7278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2011-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4480225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist