Provider Demographics
NPI:1558760694
Name:GOGOTS, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GOGOTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29W260 IROQUOIS CT N
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-2105
Mailing Address - Country:US
Mailing Address - Phone:630-290-3941
Mailing Address - Fax:
Practice Address - Street 1:416 E ROOSEVELT RD
Practice Address - Street 2:STE 107
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5589
Practice Address - Country:US
Practice Address - Phone:630-682-5090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227006970225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist