Provider Demographics
NPI:1285920181
Name:GOEDERT, MEAD (LMSW)
Entity type:Individual
Prefix:
First Name:MEAD
Middle Name:
Last Name:GOEDERT
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S WEST ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2521
Mailing Address - Country:US
Mailing Address - Phone:313-850-0469
Mailing Address - Fax:
Practice Address - Street 1:415 S WEST ST
Practice Address - Street 2:SUITE 150
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2521
Practice Address - Country:US
Practice Address - Phone:313-850-0469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010893191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical