Provider Demographics
NPI:1578025581
Name:GOUGE, GINA COOK (COTA/L)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:COOK
Last Name:GOUGE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 VAN HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4342
Mailing Address - Country:US
Mailing Address - Phone:704-883-9700
Mailing Address - Fax:
Practice Address - Street 1:2001 VAN HAVEN DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4342
Practice Address - Country:US
Practice Address - Phone:704-883-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2805224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant