Provider Demographics
NPI:1598275232
Name:GOUGH, GINA BARON (OTR/L)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:BARON
Last Name:GOUGH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 SANDY FORKS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-3814
Mailing Address - Country:US
Mailing Address - Phone:919-954-3492
Mailing Address - Fax:919-954-3947
Practice Address - Street 1:5920 SANDY FORKS RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3814
Practice Address - Country:US
Practice Address - Phone:919-954-3492
Practice Address - Fax:919-954-3947
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10083225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist