Provider Demographics
NPI:1548019508
Name:GOEMBEL, MIKE RUTLEDGE (BEHAVIOR TECHNICIAN)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:RUTLEDGE
Last Name:GOEMBEL
Suffix:
Gender:M
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 BIDDISON LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-4143
Mailing Address - Country:US
Mailing Address - Phone:443-768-9777
Mailing Address - Fax:443-768-9777
Practice Address - Street 1:1421 CLARKVIEW RD STE 130
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-2184
Practice Address - Country:US
Practice Address - Phone:844-244-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician