Provider Demographics
NPI:1053791756
Name:GOTTSLEBEN, MEGAN (ACSM EP-C)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:GOTTSLEBEN
Suffix:
Gender:F
Credentials:ACSM EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4986 N ADAMS RD STE D
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-5017
Mailing Address - Country:US
Mailing Address - Phone:248-475-4857
Mailing Address - Fax:248-475-5777
Practice Address - Street 1:4986 N ADAMS RD STE D
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48306-5017
Practice Address - Country:US
Practice Address - Phone:248-475-4857
Practice Address - Fax:248-475-5777
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI694646174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI694646OtherACSM EP-C