Provider Demographics
NPI:1952819005
Name:GOUGEON, TIFFANY LORRAINE (DPT)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:LORRAINE
Last Name:GOUGEON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 RIVER ST APT 15
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2291
Mailing Address - Country:US
Mailing Address - Phone:818-371-6041
Mailing Address - Fax:
Practice Address - Street 1:232 RIVER ST APT 15
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2291
Practice Address - Country:US
Practice Address - Phone:818-371-6041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist