Provider Demographics
NPI:1154507291
Name:GOODMAN, LAURA MARJA (MS)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARJA
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 SAINT CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-7146
Mailing Address - Country:US
Mailing Address - Phone:352-359-2115
Mailing Address - Fax:
Practice Address - Street 1:205 S 24TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4446
Practice Address - Country:US
Practice Address - Phone:217-222-0034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-19
Last Update Date:2008-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health