Provider Demographics
NPI:1649884347
Name:GOULET, EMMA BROOKS
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:BROOKS
Last Name:GOULET
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 1:6 BELLA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-1307
Mailing Address - Country:US
Mailing Address - Phone:508-840-3542
Mailing Address - Fax:
Practice Address - Street 1:6 BELLA VISTA AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-1307
Practice Address - Country:US
Practice Address - Phone:508-840-3542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS23111260390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program