Provider Demographics
NPI:1093702466
Name:MCGOUGH, JAIME MICHELLE (MPT)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:MICHELLE
Last Name:MCGOUGH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3160 OREGON DR
Mailing Address - Street 2:UNIT 8
Mailing Address - City:LOWER BURRELL
Mailing Address - State:PA
Mailing Address - Zip Code:15068-2835
Mailing Address - Country:US
Mailing Address - Phone:724-339-0897
Mailing Address - Fax:
Practice Address - Street 1:2757 LEECHBURG RD
Practice Address - Street 2:
Practice Address - City:LOWER BURRELL
Practice Address - State:PA
Practice Address - Zip Code:15068-3138
Practice Address - Country:US
Practice Address - Phone:724-337-6522
Practice Address - Fax:724-337-0630
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013558900001Medicaid