Provider Demographics
NPI:1932120607
Name:GOETZ, CAMERON A (PHD)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:A
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:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-2290
Mailing Address - Country:US
Mailing Address - Phone:920-320-8600
Mailing Address - Fax:920-320-8662
Practice Address - Street 1:339 REED AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2020
Practice Address - Country:US
Practice Address - Phone:920-320-8600
Practice Address - Fax:920-320-8662
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2345-057103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00241039OtherRAILROAD MEDICARE
Q23775OtherCIGNA
29439OtherNETWORK HEALTH PLAN
WI43576700Medicaid
WI43576700Medicaid
29439OtherNETWORK HEALTH PLAN