Provider Demographics
NPI:1144411620
Name:GOETZ, LORI ANN (PMHC)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:GOETZ
Suffix:
Gender:F
Credentials:PMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 QUAPAW ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3829
Mailing Address - Country:US
Mailing Address - Phone:505-982-8870
Mailing Address - Fax:505-982-0620
Practice Address - Street 1:1441 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4037
Practice Address - Country:US
Practice Address - Phone:505-982-8870
Practice Address - Fax:505-982-0620
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0105741101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health