Provider Demographics
NPI:1588118004
Name:GOODMAN, STACY (MSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7021 W 153RD ST
Mailing Address - Street 2:STE 5
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-5184
Mailing Address - Country:US
Mailing Address - Phone:847-322-4436
Mailing Address - Fax:888-419-1594
Practice Address - Street 1:7021 W 153RD ST
Practice Address - Street 2:STE 5
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-5184
Practice Address - Country:US
Practice Address - Phone:708-275-0934
Practice Address - Fax:888-419-1594
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490095331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical