Provider Demographics
NPI:1558626622
Name:GOERTZEN, LESLIE (LSCSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GOERTZEN
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 US HIGHWAY 50 BYP
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2230
Mailing Address - Country:US
Mailing Address - Phone:620-227-8566
Mailing Address - Fax:620-225-5824
Practice Address - Street 1:531 CAMPUS VIEW ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-7904
Practice Address - Country:US
Practice Address - Phone:620-275-0644
Practice Address - Fax:620-272-0239
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMSW 8491104100000X
KS84911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker