Healthcare Provider Details

I. General information

NPI: 1649464199
Provider Name (Legal Business Name): VICKI L. GOODWIN RN, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4636 N RAVENSWOOD AVE SUITE 201
CHICAGO IL
60640-4581
US

IV. Provider business mailing address

5919 CHURCH ST
MORTON GROVE IL
60053-2473
US

V. Phone/Fax

Practice location:
  • Phone: 847-422-3565
  • Fax:
Mailing address:
  • Phone: 847-422-3565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number041-187397
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.012290
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: