Provider Demographics
NPI:1124798830
Name:GOETZ, HOLLY RUTH (LCSW)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:RUTH
Last Name:GOETZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:RUTH
Other - Last Name:LAVINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1196 COMPTON ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-4421
Mailing Address - Country:US
Mailing Address - Phone:530-228-7565
Mailing Address - Fax:
Practice Address - Street 1:5176 HILL RD E
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6357
Practice Address - Country:US
Practice Address - Phone:707-262-5000
Practice Address - Fax:707-263-2925
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA993361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical