Provider Demographics
NPI:1164765624
Name:GOETZ, WENDY ELLEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:ELLEN
Last Name:GOETZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N WABASH AVE
Mailing Address - Street 2:SUITE 912
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3591
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 N WABASH AVE
Practice Address - Street 2:SUITE 912
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3591
Practice Address - Country:US
Practice Address - Phone:773-501-2157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2094103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical