Provider Demographics
NPI:1518139856
Name:GOTTLIEB, MEGAN (PT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:E
Other - Last Name:MUNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:1302 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5430
Practice Address - Country:US
Practice Address - Phone:607-754-7171
Practice Address - Fax:607-729-3982
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029894-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02958056Medicaid