Provider Demographics
NPI:1154990166
Name:GOGAN, AMANDA FAYE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:FAYE
Last Name:GOGAN
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 1:195 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WV
Mailing Address - Zip Code:26426-1229
Mailing Address - Country:US
Mailing Address - Phone:304-871-3053
Mailing Address - Fax:
Practice Address - Street 1:195 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WV
Practice Address - Zip Code:26426-1229
Practice Address - Country:US
Practice Address - Phone:304-871-3053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2019-3712225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty