Provider Demographics
NPI:1003483397
Name:GOETZ, TRISTA (OT)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:GOETZ
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 BROAD ST # 203
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3006
Mailing Address - Country:US
Mailing Address - Phone:386-898-0443
Mailing Address - Fax:386-898-0459
Practice Address - Street 1:290 CLYDE MORRIS BLVD STE A1
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8204
Practice Address - Country:US
Practice Address - Phone:386-898-0443
Practice Address - Fax:386-898-0459
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT21884225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist