Provider Demographics
NPI:1083902449
Name:GOATLEY, MONA LEE (PT)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:LEE
Last Name:GOATLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MONA
Other - Middle Name:LEE
Other - Last Name:CHILDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4466 W BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3170
Mailing Address - Country:US
Mailing Address - Phone:810-733-1200
Mailing Address - Fax:810-733-0688
Practice Address - Street 1:3560 PERRY LAKE RD
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-8927
Practice Address - Country:US
Practice Address - Phone:248-417-0156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1083902449Medicaid
MI0B50737OtherBLUE CROSS
MI0B50737OtherBLUE CROSS