Basic Information
| Provider Information | |||||||||
| NPI: | 1699083212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOFFARD | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | N1944 COUNTY ROAD XX | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549239761 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 S OAKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202232000 | ||||||||
| FaxNumber: | 9202230401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2010 | ||||||||
| LastUpdateDate: | 09/16/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 3345-26 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.