Provider Demographics
NPI:1457988149
Name:GOECKE, NITA J
Entity Type:Individual
Prefix:
First Name:NITA
Middle Name:J
Last Name:GOECKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3583
Mailing Address - Country:US
Mailing Address - Phone:419-999-2010
Mailing Address - Fax:419-999-6284
Practice Address - Street 1:100 DON DESCH DR
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:OH
Practice Address - Zip Code:45828-1583
Practice Address - Country:US
Practice Address - Phone:419-678-2311
Practice Address - Fax:419-678-3491
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0700261101YM0800X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI.0700261OtherLISW LICENSE
OH0396127Medicaid