Provider Demographics
NPI:1376714337
Name:SAMPLE GOSSE, HEATHER LYNN (PHD CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:LYNN
Last Name:SAMPLE GOSSE
Suffix:
Gender:F
Credentials:PHD CCC-SLP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:SAMPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:825 NE 14TH STREET
Mailing Address - Street 2:JOHN W KEYS SPEECH AND HEARING CENTER
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4649
Mailing Address - Country:US
Mailing Address - Phone:405-271-4214
Mailing Address - Fax:405-271-3360
Practice Address - Street 1:825 NE 14TH STREET
Practice Address - Street 2:JOHN W KEYS SPEECH AND HEARING CENTER
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4649
Practice Address - Country:US
Practice Address - Phone:405-271-4214
Practice Address - Fax:405-271-3360
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3349235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist