Provider Demographics
NPI:1134263403
Name:GOEBBERT, AMY (MPT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GOEBBERT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16622 W 159TH ST
Mailing Address - Street 2:UNIT 503
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-8014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16622 W 159TH ST
Practice Address - Street 2:UNIT 503
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8014
Practice Address - Country:US
Practice Address - Phone:630-204-2977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist