Provider Demographics
NPI:1669463766
Name:GOETZ, THEODORE MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:MICHAEL
Last Name:GOETZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 S LUMPKIN ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-4740
Mailing Address - Country:US
Mailing Address - Phone:706-548-9441
Mailing Address - Fax:706-354-8904
Practice Address - Street 1:1751 S LUMPKIN ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-4740
Practice Address - Country:US
Practice Address - Phone:706-548-9441
Practice Address - Fax:706-354-8904
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA698103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical