Provider Demographics
NPI:1043746100
Name:GOETZE, ELISSA MARIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:MARIE
Last Name:GOETZE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:MARIE
Other - Last Name:SHEPARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1 CREDIT UNION WAY FL 3
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:173 ESSEX ST FL 1
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907-1150
Practice Address - Country:US
Practice Address - Phone:781-586-0550
Practice Address - Fax:781-586-0125
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012610225100000X
MA23503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist