Provider Demographics
NPI:1568726164
Name:GOEHNER, CARL
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:GOEHNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 QUAIL CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3790
Mailing Address - Country:US
Mailing Address - Phone:262-695-3057
Mailing Address - Fax:
Practice Address - Street 1:1177 QUAIL CT
Practice Address - Street 2:SUITE 200
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3790
Practice Address - Country:US
Practice Address - Phone:262-695-3057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12051-24225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI123CGOEHNEMedicaid