=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194104067
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARSHA GOOCH LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 05/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 229 E MAIN ST
-----------------------------------------------------
City | GUN BARREL CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75156-3822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-288-7336
-----------------------------------------------------
Fax | 903-498-6685
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17246 FM 2613
-----------------------------------------------------
City | KEMP
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75143-5822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-288-7336
-----------------------------------------------------
Fax | 903-498-6685
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT011155
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------