Provider Demographics
NPI:1154571040
Name:GOODE, CHARLENE LABOTTE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:LABOTTE
Last Name:GOODE
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 1:245 W EXCHANGE ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-1495
Mailing Address - Country:US
Mailing Address - Phone:815-895-9227
Mailing Address - Fax:815-895-2971
Practice Address - Street 1:9056 COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-9401
Practice Address - Country:US
Practice Address - Phone:815-777-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist