Provider Demographics
NPI:1871842054
Name:GOODSON, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:GOODSON
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 1:1800 VISTA CT APT 201
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-5172
Mailing Address - Country:US
Mailing Address - Phone:708-374-8450
Mailing Address - Fax:
Practice Address - Street 1:175 E HAWTHORN PKWY
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1463
Practice Address - Country:US
Practice Address - Phone:847-868-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
IL178.012011101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst