Provider Demographics
NPI:1073645578
Name:GOBEN, BRADLEY CARLYLE (MA LCPC)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:CARLYLE
Last Name:GOBEN
Suffix:
Gender:M
Credentials:MA LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2822
Mailing Address - Country:US
Mailing Address - Phone:217-348-1354
Mailing Address - Fax:
Practice Address - Street 1:313 N MATTIS AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2460
Practice Address - Country:US
Practice Address - Phone:217-348-1086
Practice Address - Fax:217-355-4012
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional