Provider Demographics
NPI:1114585254
Name:GOLTZ, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GOLTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44225 W 12 MILE RD STE C-106
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2640
Mailing Address - Country:US
Mailing Address - Phone:248-277-3005
Mailing Address - Fax:
Practice Address - Street 1:44225 W 12 MILE RD STE C-106
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2640
Practice Address - Country:US
Practice Address - Phone:248-277-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MI7401000437103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst