Provider Demographics
NPI:1508013566
Name:GOETTL, DIANNE MARIE (NCR REFLEXOLOGIST)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:MARIE
Last Name:GOETTL
Suffix:
Gender:F
Credentials:NCR REFLEXOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724
Mailing Address - Country:US
Mailing Address - Phone:715-568-5173
Mailing Address - Fax:715-568-2673
Practice Address - Street 1:1610 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724
Practice Address - Country:US
Practice Address - Phone:715-568-5173
Practice Address - Fax:715-568-2673
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIB01208173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9455705OtherCOMMUNITY HEALTH PARTNERSHIP