Provider Demographics
NPI:1083881189
Name:GOETZ, MIRACLE NICOLE (PSY D)
Entity Type:Individual
Prefix:
First Name:MIRACLE
Middle Name:NICOLE
Last Name:GOETZ
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 RENAISSANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3018
Mailing Address - Country:US
Mailing Address - Phone:405-850-8497
Mailing Address - Fax:405-300-0643
Practice Address - Street 1:1505 RENAISSANCE BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3018
Practice Address - Country:US
Practice Address - Phone:405-850-8497
Practice Address - Fax:405-300-0643
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent