Provider Demographics
NPI:1306345632
Name:GOTTLICH, MEAGAN MICHELLE (DPT, PT)
Entity type:Individual
Prefix:
First Name:MEAGAN
Middle Name:MICHELLE
Last Name:GOTTLICH
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:MEAGAN
Other - Middle Name:MICHELLE
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT,PT
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-423-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:611 W BROWN ST STE 101
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-5816
Practice Address - Country:US
Practice Address - Phone:972-442-5287
Practice Address - Fax:972-442-3181
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27231225100000X
TX3121770225100000X
TX1301927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist