Provider Demographics
NPI:1538749460
Name:GOETTSCHE, HALLIE KRISTINE (PTA)
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:KRISTINE
Last Name:GOETTSCHE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 N 100 W
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-2030
Mailing Address - Country:US
Mailing Address - Phone:435-228-8891
Mailing Address - Fax:
Practice Address - Street 1:137 N 100 W
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2030
Practice Address - Country:US
Practice Address - Phone:435-228-8891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT121186522402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant