Provider Demographics
NPI:1780135491
Name:GOETTER, MICHAEL S (LCPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:GOETTER
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5973 DEPARTMENT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-5973
Mailing Address - Country:US
Mailing Address - Phone:630-924-1160
Mailing Address - Fax:
Practice Address - Street 1:ONE TIFFANY POINTE
Practice Address - Street 2:SUITE 110
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2915
Practice Address - Country:US
Practice Address - Phone:630-924-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008570101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.008570OtherLICENSE