Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 005104 | IA |
N | 225100000X | Physical Therapist | 3603 | AR |
NPI | 1003224544 |
---|---|
Provider Name | Traci Goltz |
First Address | Moline, IL 61265-8401 |
Second Address | Greenfield, IA 50849-9454 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/07/2014 |
Last Update Date | 29/07/2014 |