Provider Demographics
NPI:1124694682
Name:HENRY, EMILY GOUGH (OTR/L)
Entity type:Individual
Prefix:MS
First Name:EMILY
Middle Name:GOUGH
Last Name:HENRY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:EMILY
Other - Middle Name:KATHERINE
Other - Last Name:GOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1008 BYRD AVE
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:E7475 RAWHIDE RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-9025
Practice Address - Country:US
Practice Address - Phone:920-538-1424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6987-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist