Provider Demographics
NPI:1710370408
Name:GOSSARD, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:GOSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 MARTHA RD
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07640-1852
Mailing Address - Country:US
Mailing Address - Phone:201-315-3063
Mailing Address - Fax:
Practice Address - Street 1:119 E PASSAIC ST
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1342
Practice Address - Country:US
Practice Address - Phone:201-880-7787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist