Provider Demographics
NPI:1760864334
Name:GOBEN, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GOBEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 E NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:ROODHOUSE
Mailing Address - State:IL
Mailing Address - Zip Code:62082
Mailing Address - Country:US
Mailing Address - Phone:217-491-0159
Mailing Address - Fax:
Practice Address - Street 1:457 E NORTH ST
Practice Address - Street 2:
Practice Address - City:ROODHOUSE
Practice Address - State:IL
Practice Address - Zip Code:62082-1130
Practice Address - Country:US
Practice Address - Phone:217-491-0159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist