Provider Demographics
NPI:1649380924
Name:GOODMAN, DAVID JONTHAN (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JONTHAN
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 BANBURY LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3415
Mailing Address - Country:US
Mailing Address - Phone:414-324-6348
Mailing Address - Fax:
Practice Address - Street 1:282 BANBURY LN
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-3415
Practice Address - Country:US
Practice Address - Phone:414-324-6348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.011359103TC0700X
WI2581-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000084137OtherMEDICARE
WI39152500Medicaid