Provider Demographics
NPI:1154775575
Name:GOETZ, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:GOETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 WILDWATER BCH APT 1
Mailing Address - Street 2:
Mailing Address - City:MANITOU BEACH
Mailing Address - State:MI
Mailing Address - Zip Code:49253-9681
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8665 LA MESA BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:419-779-7057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16119225X00000X
OR354972225X00000X
OHOT010874225X00000X
NC13727225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist