Provider Demographics
NPI:1730651084
Name:GOODE, MICHAELA ROSE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:ROSE
Last Name:GOODE
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62044-1512
Mailing Address - Country:US
Mailing Address - Phone:217-370-7237
Mailing Address - Fax:
Practice Address - Street 1:2035 W ILES AVE STE C
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7000
Practice Address - Country:US
Practice Address - Phone:217-679-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL371001103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst