Provider Demographics
NPI:1306054663
Name:GOETZ, DARRYL ROSS (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:ROSS
Last Name:GOETZ
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 JEWEL LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-1260
Mailing Address - Country:US
Mailing Address - Phone:612-508-9019
Mailing Address - Fax:
Practice Address - Street 1:801 TWELVE OAKS CENTER DR STE 820A
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4640
Practice Address - Country:US
Practice Address - Phone:612-508-9019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1770103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist