Provider Demographics
NPI:1225593791
Name:GOODMAN, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GOODMAN
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 1:3316 CHESTNUT DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60051-2691
Mailing Address - Country:US
Mailing Address - Phone:815-307-0987
Mailing Address - Fax:
Practice Address - Street 1:1325 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2563
Practice Address - Country:US
Practice Address - Phone:815-307-0987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILG355-0119-7940390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program