Active NPI
Bradley Carlyle Goben, MA LCPC
- Professional Counselor
- Champaign, IL
National Provider Identifier
1073645578
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- Practice address
- 313 N Mattis Ave
Champaign, IL 61821-2460 - Phone
- (217) 348-1086
- Fax
- (217) 355-4012
- NPI assigned
- Mar 10, 2007
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | IL | Primary |
Addresses
Primary practice location
313 N Mattis Ave
Champaign, IL 61821-2460
Mailing address
1004 10TH St
Charleston, IL 61920-2822
Phone (217) 348-1354
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Master of Arts
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 180-003501 | IL | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1173484800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1073645578",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1004 10TH ST",
"city": "CHARLESTON",
"state": "IL",
"postal_code": "619202822",
"telephone_number": "217-348-1354"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "313 N MATTIS AVE",
"city": "CHAMPAIGN",
"state": "IL",
"postal_code": "618212460",
"telephone_number": "217-348-1086",
"fax_number": "217-355-4012"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GOBEN",
"first_name": "BRADLEY",
"middle_name": "CARLYLE",
"name_prefix": "Mr.",
"credential": "MA LCPC",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-03-10",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": "IL",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Champaign, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.