Provider Demographics
NPI:1750481289
Name:GOETZE, LAURIE (LMSW, ACSW)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:
Last Name:GOETZE
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MILITARY ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5418
Mailing Address - Country:US
Mailing Address - Phone:810-984-5575
Mailing Address - Fax:810-984-6433
Practice Address - Street 1:1101 MILITARY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5418
Practice Address - Country:US
Practice Address - Phone:810-984-5575
Practice Address - Fax:810-984-6433
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6598321041C0700X
MI68010583471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG46032022Medicare ID - Type Unspecified