Provider Demographics
NPI:1770585770
Name:GOOLD, LAURA LYNN (OTR/L LANA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:GOOLD
Suffix:
Gender:F
Credentials:OTR/L LANA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61275 VICTORY LOOP
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2820
Mailing Address - Country:US
Mailing Address - Phone:541-389-7403
Mailing Address - Fax:541-388-9236
Practice Address - Street 1:364 SE WILSON AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1711
Practice Address - Country:US
Practice Address - Phone:541-388-2681
Practice Address - Fax:541-388-9236
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00368811225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR121485Medicare ID - Type UnspecifiedLAURA GOOLD OTR/L
OR121477Medicare ID - Type UnspecifiedSOUTHSIDE PHYSICAL THERAP