Provider Demographics
NPI:1790279073
Name:GOOSE, SHAUN (COTA)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:GOOSE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 SWEETWATER RD STE 117
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-7651
Mailing Address - Country:US
Mailing Address - Phone:619-434-2063
Mailing Address - Fax:
Practice Address - Street 1:1727 SWEETWATER RD STE 117
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-7651
Practice Address - Country:US
Practice Address - Phone:619-434-2063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant