Provider Demographics
NPI:1245288067
Name:HEDGES-GOETTL, LEONARD J (PSY D)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:J
Last Name:HEDGES-GOETTL
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:LEONARD
Other - Middle Name:J
Other - Last Name:GOETTL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1088 W BALTIMORE PIKE
Mailing Address - Street 2:SUITE 2205
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5146
Mailing Address - Country:US
Mailing Address - Phone:610-744-2960
Mailing Address - Fax:610-744-2420
Practice Address - Street 1:1088 W BALTIMORE PIKE
Practice Address - Street 2:SUITE 2205
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5146
Practice Address - Country:US
Practice Address - Phone:610-744-2960
Practice Address - Fax:610-744-2420
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS009035L103TC0700X, 103T00000X
WI263827103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1451001OtherMEDICARE PTAN
WI39153700Medicaid