Provider Demographics
NPI:1225393440
Name:GOOSBY, QIANA D
Entity Type:Individual
Prefix:MS
First Name:QIANA
Middle Name:D
Last Name:GOOSBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 N 12000E RD
Mailing Address - Street 2:
Mailing Address - City:MOMENCE
Mailing Address - State:IL
Mailing Address - Zip Code:60954-3889
Mailing Address - Country:US
Mailing Address - Phone:815-472-6358
Mailing Address - Fax:
Practice Address - Street 1:300 S WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3454
Practice Address - Country:US
Practice Address - Phone:815-935-7496
Practice Address - Fax:815-935-7860
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014110225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist