Provider Demographics
NPI:1871876102
Name:GOETZEN, EZRA MF (LMHCA)
Entity type:Individual
Prefix:MR
First Name:EZRA
Middle Name:MF
Last Name:GOETZEN
Suffix:
Gender:M
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511A 26TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2336
Mailing Address - Country:US
Mailing Address - Phone:206-407-4106
Mailing Address - Fax:
Practice Address - Street 1:511A 26TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2336
Practice Address - Country:US
Practice Address - Phone:206-407-4106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60229725101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health