Provider Demographics
NPI:1639774417
Name:GOOCH, LYNSAY MARIE (OTC)
Entity Type:Individual
Prefix:
First Name:LYNSAY
Middle Name:MARIE
Last Name:GOOCH
Suffix:
Gender:F
Credentials:OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 MAPLE LEAF CT
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-6348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1839 BUFORD HWY NORTHEAST
Practice Address - Street 2:STE 100
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3672
Practice Address - Country:US
Practice Address - Phone:404-847-4382
Practice Address - Fax:404-847-4383
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374700000X
20-0710246ZX2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant
No374700000XNursing Service Related ProvidersTechnician