Provider Demographics
NPI:1871273052
Name:GOERTZ, MACKENZIE TARA (PHD)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:TARA
Last Name:GOERTZ
Suffix:
Gender:F
Credentials:PHD
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Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVENUE
Mailing Address - Street 2:PSYCHIATRY AND PSYCHOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3666
Mailing Address - Fax:414-955-6285
Practice Address - Street 1:9200 W WISCONSIN AVENUE
Practice Address - Street 2:PSYCHIATRY AND PSYCHOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3666
Practice Address - Fax:414-955-6285
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI508757103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth