Provider Demographics
NPI:1174641377
Name:GOTH, LEANNE C (MA, LP)
Entity Type:Individual
Prefix:MS
First Name:LEANNE
Middle Name:C
Last Name:GOTH
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4717 OXBOROUGH GDNS
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3994
Mailing Address - Country:US
Mailing Address - Phone:763-425-3636
Mailing Address - Fax:
Practice Address - Street 1:3300 OAKDALE AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2926
Practice Address - Country:US
Practice Address - Phone:763-520-1396
Practice Address - Fax:763-257-0073
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4081103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist