Healthcare Provider Details

I. General information

NPI: 1699386854
Provider Name (Legal Business Name): MICHAELA E GOOSIC PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHAELA E JOSLYN PTA

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3119 W FAIDLEY AVE
GRAND ISLAND NE
68803-4199
US

IV. Provider business mailing address

320 SUNFLOWER CIR
GRAND ISLAND NE
68803-3059
US

V. Phone/Fax

Practice location:
  • Phone: 308-384-2333
  • Fax:
Mailing address:
  • Phone: 308-390-5925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1186
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: