Provider Demographics
NPI:1861703191
Name:GOSHORN, MARIANNE (MSEDUC,LAT,ATC)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:GOSHORN
Suffix:
Gender:F
Credentials:MSEDUC,LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 W BRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1533
Mailing Address - Country:US
Mailing Address - Phone:765-668-7867
Mailing Address - Fax:
Practice Address - Street 1:1137 N 19TH ST
Practice Address - Street 2:
Practice Address - City:ELWOOD
Practice Address - State:IN
Practice Address - Zip Code:46036-1376
Practice Address - Country:US
Practice Address - Phone:765-552-9854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000234A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer