Provider Demographics
NPI:1407587850
Name:GOODIN, SAMANTHA JO
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:GOODIN
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 1:507 E ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3201
Mailing Address - Country:US
Mailing Address - Phone:309-686-1177
Mailing Address - Fax:
Practice Address - Street 1:507 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3201
Practice Address - Country:US
Practice Address - Phone:309-686-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-22-218796106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician