Provider Demographics
NPI:1417097700
Name:PARK-GOEDDEKE, AMY ELIZABETH (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:PARK-GOEDDEKE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14499 DRESDEN DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-4341
Mailing Address - Country:US
Mailing Address - Phone:586-939-1487
Mailing Address - Fax:
Practice Address - Street 1:12151 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-5120
Practice Address - Country:US
Practice Address - Phone:248-921-7649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010737071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical