Basic Information
| Provider Information | |||||||||
| NPI: | 1669143194 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GOELLER | ||||||||
| FirstName: | HANNAH | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2240 LYNCH AVE | ||||||||
| Address2: | |||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620404027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186106220 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3500 CENTURY DR | ||||||||
| Address2: | |||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620402166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188772700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2021 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2019040283 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 160008642 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.