Provider Demographics
NPI:1518322130
Name:GAUSE, VIRGINIA SUE (LMT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:SUE
Last Name:GAUSE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3904
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-4440
Mailing Address - Country:US
Mailing Address - Phone:214-679-7497
Mailing Address - Fax:
Practice Address - Street 1:500 E ROUND GROVE RD
Practice Address - Street 2:ROOM #11
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-8309
Practice Address - Country:US
Practice Address - Phone:214-679-7497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-24
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT123416225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist