Provider Demographics
NPI:1740491117
Name:GOZA, THERESA MARIE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:GOZA
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16224 CASTLEREA BLVD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63021-4510
Mailing Address - Country:US
Mailing Address - Phone:636-394-3401
Mailing Address - Fax:
Practice Address - Street 1:500 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3421
Practice Address - Country:US
Practice Address - Phone:636-327-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005032294104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker