Basic Information
| Provider Information | |||||||||
| NPI: | 1174641377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTH | ||||||||
| FirstName: | LEANNE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.A., L.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4717 OXBOROUGH GDNS | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554433994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634253636 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3300 OAKDALE AVE N | ||||||||
| Address2: | |||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635201396 | ||||||||
| FaxNumber: | 7632570073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP4081 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.