Basic Information
| Provider Information | |||||||||
| NPI: | 1932120607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOETZ | ||||||||
| FirstName: | CAMERON | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2290 | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542212290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203208600 | ||||||||
| FaxNumber: | 9203208662 | ||||||||
| Practice Location | |||||||||
| Address1: | 339 REED AVE | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542202020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203208600 | ||||||||
| FaxNumber: | 9203208662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 10/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2345-057 | WI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 2345-057 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | P00241039 | 01 | RAILROAD MEDICARE | OTHER | Q23775 | 01 | CIGNA | OTHER | 29439 | 01 | NETWORK HEALTH PLAN | OTHER | 43576700 | 05 | WI | MEDICAID |