Provider Demographics
NPI:1740915677
Name:GOODMAN GRAHAM, LAVETTE
Entity type:Individual
Prefix:
First Name:LAVETTE
Middle Name:
Last Name:GOODMAN GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 SOUTH BLVD APT 605
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3278
Mailing Address - Country:US
Mailing Address - Phone:201-616-8181
Mailing Address - Fax:
Practice Address - Street 1:1133 SOUTH BLVD APT 605
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-3278
Practice Address - Country:US
Practice Address - Phone:201-616-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-24
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.472420163WP0807X, 163WP0809X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult