Provider Demographics
NPI:1477813103
Name:GOETZ, MELANIE D (PTA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:D
Last Name:GOETZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 QUEENS CT
Mailing Address - Street 2:APT H
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3273
Mailing Address - Country:US
Mailing Address - Phone:734-755-7916
Mailing Address - Fax:
Practice Address - Street 1:309 E MOREHEAD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2301
Practice Address - Country:US
Practice Address - Phone:704-887-4409
Practice Address - Fax:866-231-5080
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004413A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant