Provider Demographics
NPI:1326051863
Name:GOFORTH, DENISE M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:M
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 N UNIVERSITY ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4781
Mailing Address - Country:US
Mailing Address - Phone:309-692-7778
Mailing Address - Fax:309-692-7779
Practice Address - Street 1:5016 N UNIVERSITY ST
Practice Address - Street 2:SUITE 105
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4781
Practice Address - Country:US
Practice Address - Phone:309-692-7778
Practice Address - Fax:309-692-7779
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0000261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical