Provider Demographics
NPI:1265026595
Name:GOEBEL, ELLEN CAROL (OTR)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:CAROL
Last Name:GOEBEL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:CAROL
Other - Last Name:SWEDZINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:9346 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-9422
Mailing Address - Country:US
Mailing Address - Phone:952-223-2506
Mailing Address - Fax:
Practice Address - Street 1:5232 KYLER AVE NE
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-4634
Practice Address - Country:US
Practice Address - Phone:952-223-2506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MN106450225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
442937OtherNBCOT