Provider Demographics
NPI:1922083294
Name:GOUDY, ANDREA LEA (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:LEA
Last Name:GOUDY
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W WILSON ST
Mailing Address - Street 2:STE 7
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-1975
Mailing Address - Country:US
Mailing Address - Phone:630-879-9132
Mailing Address - Fax:630-879-9132
Practice Address - Street 1:106 W WILSON ST
Practice Address - Street 2:STE 7
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-1975
Practice Address - Country:US
Practice Address - Phone:630-879-9132
Practice Address - Fax:630-879-9132
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
640220Medicare ID - Type Unspecified