Healthcare Provider Details

I. General information

NPI: 1659595346
Provider Name (Legal Business Name): LINDA MARIE GOFORTH SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2923 198TH PL
LYNWOOD IL
60411-4546
US

IV. Provider business mailing address

2923 198TH PL
LYNWOOD IL
60411-4546
US

V. Phone/Fax

Practice location:
  • Phone: 708-299-4799
  • Fax:
Mailing address:
  • Phone: 708-299-4799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146007330
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: