Provider Demographics
NPI:1043370208
Name:GOETZ, KATHERINE GARDNER (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:GARDNER
Last Name:GOETZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6635 N MOZART ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-4307
Mailing Address - Country:US
Mailing Address - Phone:773-262-6133
Mailing Address - Fax:
Practice Address - Street 1:200 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-1718
Practice Address - Country:US
Practice Address - Phone:708-481-9799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical