Provider Demographics
NPI:1780978023
Name:GOETZ, MARK CHRISTOPHER (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CHRISTOPHER
Last Name:GOETZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 14TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372
Mailing Address - Country:US
Mailing Address - Phone:253-697-2700
Mailing Address - Fax:
Practice Address - Street 1:11269 JEFFERSON HWY N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3123
Practice Address - Country:US
Practice Address - Phone:763-236-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TR0400X, 103T00000X, 103TC1900X, 103TF0000X, 103TH0004X
WAPY60230406208100000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth