Provider Demographics
NPI:1265885875
Name:COUGHLIN, EMILY GOLD (PTA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:GOLD
Last Name:COUGHLIN
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 1:20000 VICTOR PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-7027
Mailing Address - Country:US
Mailing Address - Phone:734-743-2909
Mailing Address - Fax:
Practice Address - Street 1:20000 VICTOR PKWY STE 100
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:734-743-2909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000822225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23-5634Medicare PIN