Provider Demographics
NPI:1053335232
Name:GOETZE, HENRY J (PHD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:J
Last Name:GOETZE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:HENRY
Other - Middle Name:J
Other - Last Name:GOETZE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 8572
Mailing Address - Street 2:100 W. BEAVER CREEK BLVD, SUITE 218
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-8572
Mailing Address - Country:US
Mailing Address - Phone:845-594-4692
Mailing Address - Fax:845-471-1815
Practice Address - Street 1:100 W. BEAVER CREEK BLVD
Practice Address - Street 2:SUITE 218
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620-8572
Practice Address - Country:US
Practice Address - Phone:845-594-4692
Practice Address - Fax:845-471-1815
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007274103TC0700X
CO3047103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
01-0592394OtherTAX ID
NYV46822Medicare ID - Type Unspecified
NY010592394Medicare UPIN