Provider Demographics
NPI:1457439796
Name:GOSSEN, AMY MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:GOSSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MICHELLE
Other - Last Name:CYR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1911 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-3178
Mailing Address - Country:US
Mailing Address - Phone:417-358-0209
Mailing Address - Fax:417-358-3207
Practice Address - Street 1:1911 BUENA VISTA AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-3178
Practice Address - Country:US
Practice Address - Phone:417-358-0209
Practice Address - Fax:417-358-3207
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20874225100000X
MO2007010485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist