Provider Demographics
NPI:1760052815
Name:GOHEEN, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:GOHEEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 VIRGINIA ST E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-3011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1333 VIRGINIA ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3011
Practice Address - Country:US
Practice Address - Phone:304-412-1146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker