Provider Demographics
NPI:1740708171
Name:GOODIN, THERESA ALEISE (MA-CCC-SLP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ALEISE
Last Name:GOODIN
Suffix:
Gender:F
Credentials:MA-CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5004
Mailing Address - Country:US
Mailing Address - Phone:618-457-3371
Mailing Address - Fax:
Practice Address - Street 1:1301 EAST WALNUT STREET
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-457-3371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.006824235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist