Provider Demographics
NPI:1679579973
Name:GOULD, SUSAN S (OT/CHT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:GOULD
Suffix:
Gender:F
Credentials:OT/CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:706-236-2758
Mailing Address - Fax:706-802-1408
Practice Address - Street 1:201 TURNER MCCALL BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2545
Practice Address - Country:US
Practice Address - Phone:706-236-2758
Practice Address - Fax:706-802-1408
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001129225X00000X
GA10011020003225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA67BBBNCMedicare PIN