Provider Demographics
NPI:1366687345
Name:GOUDREAU, JODY ELLEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:ELLEN
Last Name:GOUDREAU
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 1:82 BARRETT RD
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:NH
Mailing Address - Zip Code:03257-5806
Mailing Address - Country:US
Mailing Address - Phone:603-783-5530
Mailing Address - Fax:
Practice Address - Street 1:82 BARRETT RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:NH
Practice Address - Zip Code:03257-5806
Practice Address - Country:US
Practice Address - Phone:603-783-5530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1285225X00000X
VT0720000547225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist