Provider Demographics
NPI:1376659920
Name:GOODALE-BUTTIMER, DESIREE ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:ANN
Last Name:GOODALE-BUTTIMER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:DESIREE
Other - Middle Name:ANN
Other - Last Name:GOODALE-MIKOSZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:15300 WEST AVE STE 313
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4687
Mailing Address - Country:US
Mailing Address - Phone:708-923-7878
Mailing Address - Fax:708-923-7888
Practice Address - Street 1:15300 WEST AVE STE 313
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4687
Practice Address - Country:US
Practice Address - Phone:708-923-7878
Practice Address - Fax:708-923-7888
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0081271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400342793OtherMEDICARE PTAN
IL$$$$$$$$$001Medicaid