Provider Demographics
NPI:1548690704
Name:GOETSCH, DIANNE M
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:M
Last Name:GOETSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23400 PARK ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2545
Mailing Address - Country:US
Mailing Address - Phone:313-528-9146
Mailing Address - Fax:
Practice Address - Street 1:3070 LINDENWOOD DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1312
Practice Address - Country:US
Practice Address - Phone:313-528-9146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361003450103TC0700X, 103T00000X
MI6301015777103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist