Provider Demographics
NPI:1013738962
Name:GOODWIN, ROBERT LESLEY (LPC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LESLEY
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 MONTGOMERY PL
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62522-2654
Mailing Address - Country:US
Mailing Address - Phone:217-309-5821
Mailing Address - Fax:
Practice Address - Street 1:320 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-4665
Practice Address - Country:US
Practice Address - Phone:217-877-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018364101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health