Healthcare Provider Details

I. General information

NPI: 1710213178
Provider Name (Legal Business Name): AMANDA DIANNE GOUGH MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W LINCOLN AVE
CHARLESTON IL
61920-3070
US

IV. Provider business mailing address

125 W JACKSON AVE
CHARLESTON IL
61920-1814
US

V. Phone/Fax

Practice location:
  • Phone: 217-345-9600
  • Fax:
Mailing address:
  • Phone: 618-562-2449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.002672
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: