Provider Demographics
NPI:1134556475
Name:GOGUEN, STACY (MS OTR/L)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GOGUEN
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8893 CYPRESS PRESERVE PL
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-0829
Mailing Address - Country:US
Mailing Address - Phone:239-481-4125
Mailing Address - Fax:
Practice Address - Street 1:14421 METROPOLIS AVE STE 103
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4323
Practice Address - Country:US
Practice Address - Phone:239-561-2778
Practice Address - Fax:239-561-8107
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15900225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist