Provider Demographics
NPI:1891278685
Name:GOSS, ERICA LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNN
Last Name:GOSS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5402 KAYWAY DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-6410
Mailing Address - Country:US
Mailing Address - Phone:903-522-2933
Mailing Address - Fax:
Practice Address - Street 1:4400 WALNUT ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5586
Practice Address - Country:US
Practice Address - Phone:872-990-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2122837208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1083673818Medicaid