Provider Demographics
NPI:1730428087
Name:GOECKERMAN, NICOLE MARIE (PTA)
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MARIE
Last Name:GOECKERMAN
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 1:3130 CENTRAL PARK W
Mailing Address - Street 2:SUITE A
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1094
Mailing Address - Country:US
Mailing Address - Phone:419-841-9622
Mailing Address - Fax:419-843-8288
Practice Address - Street 1:3130 CENTRAL PARK W
Practice Address - Street 2:SUITE A
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1094
Practice Address - Country:US
Practice Address - Phone:419-841-9622
Practice Address - Fax:419-843-8288
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08457225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant