Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker |
NPI | 1003042722 |
---|---|
Provider Name | Alice Goertz |
First Address | Bristol, IN 46507-9192 |
Second Address | South Bend, IN 46617-2322 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2009 |
Last Update Date | 09/06/2009 |