Basic Information
| Provider Information | |||||||||
| NPI: | 1003483397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOETZ | ||||||||
| FirstName: | TRISTA | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 336 BROAD ST # 203 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3868980443 | ||||||||
| FaxNumber: | 3868980459 | ||||||||
| Practice Location | |||||||||
| Address1: | 290 CLYDE MORRIS BLVD STE A1 | ||||||||
| Address2: | |||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321748204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3868980443 | ||||||||
| FaxNumber: | 3868980459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2021 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT21884 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.