Provider Demographics
NPI:1700340916
Name:GOELTZ, GAVIN THOMAS
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:THOMAS
Last Name:GOELTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 ALDRO RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7826
Mailing Address - Country:US
Mailing Address - Phone:715-781-8788
Mailing Address - Fax:
Practice Address - Street 1:763 ALDRO RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7826
Practice Address - Country:US
Practice Address - Phone:715-781-8788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer