Provider Demographics
NPI:1548858897
Name:GOUGH, BREANA FAYE
Entity type:Individual
Prefix:MRS
First Name:BREANA
Middle Name:FAYE
Last Name:GOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 SUGARTREE DR
Mailing Address - Street 2:
Mailing Address - City:LIPAN
Mailing Address - State:TX
Mailing Address - Zip Code:76462-9609
Mailing Address - Country:US
Mailing Address - Phone:432-270-8177
Mailing Address - Fax:
Practice Address - Street 1:1400 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-926-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist