Provider Demographics
NPI:1861516619
Name:GOLL, JOHN (LMFT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GOLL
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 WING LN
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2340
Mailing Address - Country:US
Mailing Address - Phone:317-289-0982
Mailing Address - Fax:
Practice Address - Street 1:2100 MANCHESTER RD STE 400-A
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-4579
Practice Address - Country:US
Practice Address - Phone:703-348-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001611A106H00000X
VA0717001255106H00000X
IL166.001069106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist