Provider Demographics
NPI:1689864142
Name:GOERLITZ, BETH ELLEN (CCC, SLP)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ELLEN
Last Name:GOERLITZ
Suffix:
Gender:F
Credentials:CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5946 PARK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-7547
Mailing Address - Country:US
Mailing Address - Phone:386-846-2161
Mailing Address - Fax:
Practice Address - Street 1:305 CLYDE MORRIS BLVD STE 220
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8187
Practice Address - Country:US
Practice Address - Phone:386-676-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist