MEDICARE: MOLLY MARY GOODMAN BSW, MSW, SSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker		IL

General Provider Information

NPI Number	:	1679447007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY MARY GOODMAN BSW, MSW, SSW

Provider Business Mailing Address
First Line	:	17868 TOWNSHIP ROAD 500 N
Second Line	:
City	:	WYOMING
State	:	IL
Zip	:	61491-8939
Country	:	US
Telephone Number	:	309-883-2405
Fax Number	:

Provider Business Practice Location Address
First Line	:	7820 N UNIVERSITY ST STE 101
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-8301
Country	:	US
Telephone Number	:	309-253-2471
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2025
Last Update Date	:	09/30/2025

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