Provider Demographics
NPI:1780759092
Name:MCCOULF, MICHAEL PATRICK (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:MCCOULF
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2783 NIAGARA FALLS BLVD
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14304-4516
Mailing Address - Country:US
Mailing Address - Phone:716-430-9009
Mailing Address - Fax:
Practice Address - Street 1:2783 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304-4516
Practice Address - Country:US
Practice Address - Phone:716-430-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0220681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01465154Medicaid