Provider Demographics
NPI:1215064365
Name:GODFREY, KATHERINE ANN (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:GODFREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1701 E WOODFIELD ROAD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-5113
Mailing Address - Country:US
Mailing Address - Phone:847-240-2211
Mailing Address - Fax:847-240-2418
Practice Address - Street 1:390 E CONGRESS PKWY
Practice Address - Street 2:SUITE J
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6202
Practice Address - Country:US
Practice Address - Phone:815-356-5050
Practice Address - Fax:815-356-5094
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361076212084N0400X
IL036-1076212084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D91973Medicare UPIN
ILK36921Medicare PIN