Provider Demographics
NPI:1285959619
Name:GOETZ, JEREMY (LLMSW)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:GOETZ
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 BOLINGBROKE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1067
Mailing Address - Country:US
Mailing Address - Phone:586-549-8320
Mailing Address - Fax:
Practice Address - Street 1:2122 15 MILE RD
Practice Address - Street 2:SUITE B
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4853
Practice Address - Country:US
Practice Address - Phone:586-264-3692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801091901104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker