Provider Demographics
NPI:1962523456
Name:GOETSCH, VIRGINIA L (PHD)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:L
Last Name:GOETSCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2075
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30031-2075
Mailing Address - Country:US
Mailing Address - Phone:770-301-3578
Mailing Address - Fax:
Practice Address - Street 1:755 COMMERCE DR
Practice Address - Street 2:SUITE 903
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2627
Practice Address - Country:US
Practice Address - Phone:770-301-3578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY2269103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000820817CMedicaid