Provider Demographics
NPI:1578610051
Name:GOETZ, HOLLY L (OT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:L
Last Name:GOETZ
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:L
Other - Last Name:HEASLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:13025 8TH ST
Mailing Address - Street 2:
Mailing Address - City:OSSEO
Mailing Address - State:WI
Mailing Address - Zip Code:54758-7634
Mailing Address - Country:US
Mailing Address - Phone:715-597-7907
Mailing Address - Fax:
Practice Address - Street 1:13025 8TH ST
Practice Address - Street 2:
Practice Address - City:OSSEO
Practice Address - State:WI
Practice Address - Zip Code:54758-7634
Practice Address - Country:US
Practice Address - Phone:715-597-7907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4347225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40897300Medicaid
1076306OtherNBCOT CERT