Healthcare Provider Details

I. General information

NPI: 1245288067
Provider Name (Legal Business Name): LEONARD J HEDGES-GOETTL PSY. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LEONARD J GOETTL

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1088 W BALTIMORE PIKE SUITE 2205
MEDIA PA
19063-5146
US

IV. Provider business mailing address

1088 W BALTIMORE PIKE SUITE 2205
MEDIA PA
19063-5146
US

V. Phone/Fax

Practice location:
  • Phone: 610-744-2960
  • Fax: 610-744-2420
Mailing address:
  • Phone: 610-744-2960
  • Fax: 610-744-2420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number263827
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS009035L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS009035L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: