Healthcare Provider Details

I. General information

NPI: 1669957239
Provider Name (Legal Business Name): SUSAN G GOBEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2018
Last Update Date: 09/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11430 KESTREL CT
EVANSVILLE IN
47725-9796
US

IV. Provider business mailing address

11430 KESTREL CT
EVANSVILLE IN
47725-9796
US

V. Phone/Fax

Practice location:
  • Phone: 812-454-8481
  • Fax:
Mailing address:
  • Phone: 812-454-8481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: