Provider Demographics
NPI:1083852693
Name:GOSS, JULIE MARIE (LAC)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:MARIE
Last Name:GOSS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MS
Other - First Name:JULIE
Other - Middle Name:MARIE
Other - Last Name:GOSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC, MACOM
Mailing Address - Street 1:5425 SE RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-4853
Mailing Address - Country:US
Mailing Address - Phone:971-322-8575
Mailing Address - Fax:
Practice Address - Street 1:5425 SE RAYMOND ST.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2502
Practice Address - Country:US
Practice Address - Phone:971-322-8575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPENDING171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
110375OtherNCCAOM CERTIFIED ACUPUNCTURIST