Provider Demographics
NPI:1942824545
Name:GOUGH, MAYA S
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:S
Last Name:GOUGH
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 1:10284 W VIRGINIA CITY ST
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5619
Mailing Address - Country:US
Mailing Address - Phone:208-284-4922
Mailing Address - Fax:
Practice Address - Street 1:10284 W VIRGINIA CITY ST
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5619
Practice Address - Country:US
Practice Address - Phone:208-284-4922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-31
Last Update Date:2020-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer