Provider Demographics
NPI:1649464199
Name:GOODWIN, VICKI L (RN, LCSW)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:RN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5919 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2473
Mailing Address - Country:US
Mailing Address - Phone:847-422-3565
Mailing Address - Fax:
Practice Address - Street 1:4636 N RAVENSWOOD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4581
Practice Address - Country:US
Practice Address - Phone:847-422-3565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-187397163WH0200X
IL149.0122901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163WH0200XNursing Service ProvidersRegistered NurseHome Health