Healthcare Provider Details

I. General information

NPI: 1366371957
Provider Name (Legal Business Name): CORETTA GODBOLD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N GREENLEAF ST STE B
GURNEE IL
60031-3326
US

IV. Provider business mailing address

710 GLEN ROCK AVE APT 2
WAUKEGAN IL
60085-5460
US

V. Phone/Fax

Practice location:
  • Phone: 847-390-2271
  • Fax:
Mailing address:
  • Phone: 847-390-2271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberG314-1007-2713
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: