Provider Demographics
NPI:1003886938
Name:GODY, DALE SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:SUSAN
Last Name:GODY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 OLD GLENVIEW RD
Mailing Address - Street 2:SUITE 16
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2963
Mailing Address - Country:US
Mailing Address - Phone:847-251-7774
Mailing Address - Fax:847-251-9897
Practice Address - Street 1:3330 OLD GLENVIEW RD
Practice Address - Street 2:SUITE 16
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2963
Practice Address - Country:US
Practice Address - Phone:847-251-7774
Practice Address - Fax:847-251-9897
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002314103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL616930Medicare ID - Type Unspecified