MEDICARE: MR. JEREMY GOETZ L.L.M.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	6801091901	MI

General Provider Information

NPI Number	:	1285959619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEREMY GOETZ L.L.M.S.W.

Provider Business Mailing Address
First Line	:	2951 BOLINGBROKE DR
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-1067
Country	:	US
Telephone Number	:	586-549-8320
Fax Number	:

Provider Business Practice Location Address
First Line	:	2122 15 MILE RD
Second Line	:	SUITE B
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-4853
Country	:	US
Telephone Number	:	586-264-3692
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2010
Last Update Date	:	03/29/2010

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