MEDICARE: ALISON LEE GOETGELUCK DPT

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	225100000X	Physical Therapist	5501015495	MI
2	225100000X	Physical Therapist	070019795	IL

General Provider Information

NPI Number	:	1982901203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISON LEE GOETGELUCK DPT

Provider Business Mailing Address
First Line	:	1435 W ADDISON ST
Second Line	:	APT 2
City	:	CHICAGO
State	:	IL
Zip	:	60613-4375
Country	:	US
Telephone Number	:	248-231-0759
Fax Number	:

Provider Business Practice Location Address
First Line	:	1435 W ADDISON ST
Second Line	:	APT 2
City	:	CHICAGO
State	:	IL
Zip	:	60613-4375
Country	:	US
Telephone Number	:	847-723-4532
Fax Number	:	847-723-4353

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

Provider Enumeration Date	:	02/23/2011
Last Update Date	:	10/14/2014

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