Healthcare Provider Details

I. General information

NPI: 1528443421
Provider Name (Legal Business Name): HEIDI GOELZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21393 NOVAK AVE N
SCANDIA MN
55073-9451
US

IV. Provider business mailing address

21393 NOVAK AVE N
SCANDIA MN
55073-9451
US

V. Phone/Fax

Practice location:
  • Phone: 651-433-4736
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number101079
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: