Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | OT21884 | FL |
NPI | 1003483397 |
---|---|
Provider Name | Trista Goetz |
First Address | Rome, GA 30161-3006 |
Second Address | Ormond Beach, FL 32174-8204 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2021 |
Last Update Date | 07/06/2021 |