Healthcare Provider Details

I. General information

NPI: 1013738962
Provider Name (Legal Business Name): ROBERT LESLEY GOODWIN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E CENTRAL AVE
DECATUR IL
62521-4665
US

IV. Provider business mailing address

90 MONTGOMERY PL
DECATUR IL
62522-2654
US

V. Phone/Fax

Practice location:
  • Phone: 217-877-9117
  • Fax:
Mailing address:
  • Phone: 217-309-5821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.018364
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: