Provider Demographics
NPI:1962710962
Name:GOETZE, SHIRLEY JANE (CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:JANE
Last Name:GOETZE
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15693 COUNTY ROAD 373
Mailing Address - Street 2:
Mailing Address - City:GLADEWATER
Mailing Address - State:TX
Mailing Address - Zip Code:75647-9160
Mailing Address - Country:US
Mailing Address - Phone:903-877-3709
Mailing Address - Fax:
Practice Address - Street 1:1200 DUDLEY RD
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3306
Practice Address - Country:US
Practice Address - Phone:903-984-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17553235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX17553OtherSPEECH, LANGUAGE PATHOLOGY LICENSE