=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710100730
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNE A GOLUCH P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 W MAPLE AVE
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72764-5333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-253-1815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 266 COUNTY ROAD 3027
-----------------------------------------------------
City | EUREKA SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72632-9721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-253-1815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | PT2620
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------