Basic Information
| Provider Information | |||||||||
| NPI: | 1427484898 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOETTLICHER | ||||||||
| FirstName: | LUKE | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3833 COON RAPIDS BLVD NW STE 120 | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637673350 | ||||||||
| FaxNumber: | 7637670912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2013 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 302300 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.