Provider Demographics
NPI:1982687018
Name:GOECKNER, DANIEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:GOECKNER
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 1:11649 N PORT WASHINGTON RD STE 206
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3459
Mailing Address - Country:US
Mailing Address - Phone:262-241-9990
Mailing Address - Fax:
Practice Address - Street 1:11649 N PORT WASHINGTON RD STE 206
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092
Practice Address - Country:US
Practice Address - Phone:262-241-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI850-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000084456Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
WI39-1559516Medicare UPIN