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General NPI Number Information
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NPI Number | 1720550072
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Entity Type | Individual
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Provider Name | TERESA LYNNE GOEDTEL LPTA
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Gender | Female
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Dates
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Enumeration Date | 12/27/2018
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Last Update Date | 12/27/2018
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Provider Practice Location Address
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Address Line | 27733 SCHOENHERR RD
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City | WARREN
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State | MI
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Zip | 48088-6641
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Country | US
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Telephone | 586-427-6640
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Fax |
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Provider Business Mailing Address
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Address Line | 198 S MAIN ST
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City | MOUNT CLEMENS
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State | MI
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Zip | 48043-7917
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Country | US
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Telephone | 586-477-1402
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 5502001978
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License Number State | MI
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