Healthcare Provider Details

I. General information

NPI: 1265256010
Provider Name (Legal Business Name): MISS MARLINE LOUISEDITH GOUSSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 S CENTER ST
FRACKVILLE PA
17931-1647
US

IV. Provider business mailing address

150 CHAMBERLAINE AVE
POTTSVILLE PA
17901-8648
US

V. Phone/Fax

Practice location:
  • Phone: 570-593-5484
  • Fax:
Mailing address:
  • Phone: 570-593-5484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: