Provider Demographics
NPI:1174081350
Name:GOUVEIA, FALLON MARY (OTR/L, LAT, ATC)
Entity type:Individual
Prefix:MISS
First Name:FALLON
Middle Name:MARY
Last Name:GOUVEIA
Suffix:
Gender:F
Credentials:OTR/L, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2876 RINGNECK RD
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:PA
Mailing Address - Zip Code:19403-1817
Mailing Address - Country:US
Mailing Address - Phone:484-784-7824
Mailing Address - Fax:
Practice Address - Street 1:414 PAOLI PIKE
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3311
Practice Address - Country:US
Practice Address - Phone:484-784-7824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X, 390200000X
PAO3018293225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program