Provider Demographics
NPI:1114952314
Name:GOODMAN, DIANE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 JAMES ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2173
Mailing Address - Country:US
Mailing Address - Phone:630-251-8434
Mailing Address - Fax:630-208-1044
Practice Address - Street 1:515 JAMES ST STE 1
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2187
Practice Address - Country:US
Practice Address - Phone:630-251-8434
Practice Address - Fax:630-208-1044
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008020103T00000X
IL180-002613101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional