Healthcare Provider Details

I. General information

NPI: 1649380924
Provider Name (Legal Business Name): DAVID JONTHAN GOODMAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/07/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 BANBURY LN
GRAYSLAKE IL
60030-3415
US

IV. Provider business mailing address

282 BANBURY LN
GRAYSLAKE IL
60030-3415
US

V. Phone/Fax

Practice location:
  • Phone: 414-324-6348
  • Fax:
Mailing address:
  • Phone: 414-324-6348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2581-057
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.011359
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: