Provider Demographics
NPI:1265186233
Name:GOEBEL, STACEY MICHELLE (OTR)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
Last Name:GOEBEL
Suffix:
Gender:
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 FULLER AVE NE STE 105
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3459
Mailing Address - Country:US
Mailing Address - Phone:616-327-6191
Mailing Address - Fax:616-333-4928
Practice Address - Street 1:2922 FULLER AVE NE STE 105
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3459
Practice Address - Country:US
Practice Address - Phone:616-327-6191
Practice Address - Fax:616-333-4928
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201012832225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist