Provider Demographics
NPI:1982901203
Name:GOETGELUCK, ALISON LEE (DPT)
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:LEE
Last Name:GOETGELUCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ALISON
Other - Middle Name:LEE
Other - Last Name:FREELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1435 W ADDISON ST
Mailing Address - Street 2:APT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4375
Mailing Address - Country:US
Mailing Address - Phone:248-231-0759
Mailing Address - Fax:
Practice Address - Street 1:1435 W ADDISON ST
Practice Address - Street 2:APT 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-4375
Practice Address - Country:US
Practice Address - Phone:847-723-4532
Practice Address - Fax:847-723-4353
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015495225100000X
IL070019795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236629Medicare PIN