Healthcare Provider Details

I. General information

NPI: 1235342643
Provider Name (Legal Business Name): ERIC LYLE GOSSELIN P.T., ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 VESPER ST APT 1
PORTLAND ME
04101-4493
US

IV. Provider business mailing address

275 BATH RD SUITE 2
BRUNSWICK ME
04011-2671
US

V. Phone/Fax

Practice location:
  • Phone: 407-791-3723
  • Fax:
Mailing address:
  • Phone: 407-791-3723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT3292
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 22300
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17755
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 1851
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: