Provider Demographics
NPI:1467779553
Name:GOGGLEYE, WARREN (CD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:
Last Name:GOGGLEYE
Suffix:
Gender:M
Credentials:CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 S POKEGAMA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3831
Mailing Address - Country:US
Mailing Address - Phone:218-327-9944
Mailing Address - Fax:
Practice Address - Street 1:604 S POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3831
Practice Address - Country:US
Practice Address - Phone:218-327-9944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302475101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN302475OtherSTATE LICENSE