Provider Demographics
NPI:1659485878
Name:DAVID GOODMAN, PH.D. PSYCHOLOGIST LTD.
Entity Type:Organization
Organization Name:DAVID GOODMAN, PH.D. PSYCHOLOGIST LTD.
Other - Org Name:DAVID GOODMAN, PH.D. PSYCHOLOGIST ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:630-377-3535
Mailing Address - Street 1:405 ILLINOIS AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2963
Mailing Address - Country:US
Mailing Address - Phone:630-377-3535
Mailing Address - Fax:630-530-9527
Practice Address - Street 1:405 ILLINOIS AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2963
Practice Address - Country:US
Practice Address - Phone:630-377-3535
Practice Address - Fax:630-530-9527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002731103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4572009OtherBC/BS PROVIDER NUMBER
IL4572009OtherBC/BS PROVIDER NUMBER