Provider Demographics
NPI:1598247298
Name:GOUGH, LARRY CHRISTOPHER (PTA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:CHRISTOPHER
Last Name:GOUGH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:CHRIS
Other - Middle Name:
Other - Last Name:GOUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:3650 S INTERSTATE 35 E
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165
Mailing Address - Country:US
Mailing Address - Phone:972-937-7320
Mailing Address - Fax:
Practice Address - Street 1:3650 S INTERSTATE 35 E
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165
Practice Address - Country:US
Practice Address - Phone:972-937-7320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2074909208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2074909OtherPHYSICAL THERAPY ASSISTANT LICENSE