Provider Demographics
NPI:1750772125
Name:GOODMAN, ELISE (DPT)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:
Other - Last Name:BECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:850 43RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:902 ILLINI DR
Practice Address - Street 2:
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-4700
Practice Address - Country:US
Practice Address - Phone:309-796-3450
Practice Address - Fax:309-796-3460
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-021320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist