Provider Demographics
NPI:1134463706
Name:GOETZ, PAUL WILLIAM (PHD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:WILLIAM
Last Name:GOETZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E HURON ST STE 11-140
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2968
Mailing Address - Country:US
Mailing Address - Phone:312-695-2734
Mailing Address - Fax:
Practice Address - Street 1:201 E HURON ST STE 11-140
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2968
Practice Address - Country:US
Practice Address - Phone:312-695-2734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008459103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical