Provider Demographics
NPI:1104151331
Name:GOOSSENS, LIZA M (PTA)
Entity type:Individual
Prefix:MS
First Name:LIZA
Middle Name:M
Last Name:GOOSSENS
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 1:63 COMANCHE DR
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-1015
Mailing Address - Country:US
Mailing Address - Phone:901-262-1383
Mailing Address - Fax:
Practice Address - Street 1:765 BERT JOHNSTON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-2414
Practice Address - Country:US
Practice Address - Phone:901-475-0027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4557225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant