Provider Demographics
NPI:1235342643
Name:GOSSELIN, ERIC LYLE (PT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LYLE
Last Name:GOSSELIN
Suffix:
Gender:M
Credentials:PT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 BATH RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2671
Mailing Address - Country:US
Mailing Address - Phone:407-791-3723
Mailing Address - Fax:
Practice Address - Street 1:82 VESPER ST
Practice Address - Street 2:APT 1
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4493
Practice Address - Country:US
Practice Address - Phone:407-791-3723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT32922251X0800X
FLPT 22300225100000X
MA17755225100000X
FLAL 18512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer