Basic Information
| Provider Information | |||||||||
| NPI: | 1215485990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOETTSCH | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | SWT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7426 E HUNTINGTON DR | ||||||||
| Address2: | APT 1 | ||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445124072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305013224 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1325 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445041702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307431015 | ||||||||
| FaxNumber: | 3307431025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2016 | ||||||||
| LastUpdateDate: | 09/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1610121-TRNE | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.