Provider Demographics
NPI:1720550072
Name:GOEDTEL, TERESA LYNNE (LPTA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNNE
Last Name:GOEDTEL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-7917
Mailing Address - Country:US
Mailing Address - Phone:586-477-1402
Mailing Address - Fax:
Practice Address - Street 1:27733 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6641
Practice Address - Country:US
Practice Address - Phone:586-427-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001978225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty