Provider Demographics
NPI:1225018815
Name:GOOSSENS, THOMAS ALBERT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ALBERT
Last Name:GOOSSENS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 N UNIVERSITY ST
Mailing Address - Street 2:SUITE 221-A
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1278
Mailing Address - Country:US
Mailing Address - Phone:309-689-8878
Mailing Address - Fax:309-689-8878
Practice Address - Street 1:7501 N UNIVERSITY ST
Practice Address - Street 2:SUITE 221-A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1278
Practice Address - Country:US
Practice Address - Phone:309-689-8878
Practice Address - Fax:309-689-8878
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2016-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149008315101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
K15585Medicare ID - Type Unspecified