1679447007 NPI number — MOLLY MARY GOODMAN BSW, MSW, SSW

Table of content: MOLLY MARY GOODMAN BSW, MSW, SSW (NPI 1679447007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679447007 NPI number — MOLLY MARY GOODMAN BSW, MSW, SSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODMAN
Provider First Name:
MOLLY
Provider Middle Name:
MARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BSW, MSW, SSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARLTON
Provider Other First Name:
MOLLY
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BSW, MSW, SSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679447007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7820 N UNIVERSITY ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-8301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-253-2471
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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