1801805577 NPI number — KATHLEEN ELLEN MCGOUGH-EVANS OT

Table of content: KATHLEEN ELLEN MCGOUGH-EVANS OT (NPI 1801805577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801805577 NPI number — KATHLEEN ELLEN MCGOUGH-EVANS OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGOUGH-EVANS
Provider First Name:
KATHLEEN
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCGOUGH
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801805577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 TERRACE DR STE 118
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYPHANT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18447-2501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-483-4603
Provider Business Mailing Address Fax Number:
570-319-1250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 TERRACE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYPHANT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-483-4603
Provider Business Practice Location Address Fax Number:
570-319-1250
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OC005140L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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