Provider Demographics
NPI:1881832822
Name:GOUGH, MARY ELLEN (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:GOUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:MISCHEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:40644 SAINT LOUIS DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7129
Mailing Address - Country:US
Mailing Address - Phone:586-416-4429
Mailing Address - Fax:
Practice Address - Street 1:42536 HAYES RD STE 100
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3644
Practice Address - Country:US
Practice Address - Phone:586-286-9644
Practice Address - Fax:586-286-9647
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist