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NPI Code Detail

MEDICARE: MR. LARRY ALLEN GOLDMAN LICSW

MEDICARE: MR. LARRY ALLEN GOLDMAN LICSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker539MN

General Provider Information

NPI Number : 1336244425
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. LARRY ALLEN GOLDMAN LICSW
Provider Business Mailing Address
First Line : 6860 SHINGLE CREEK PKWY
Second Line : SUITE 116
City : BROOKLYN CENTER
State : MN
Zip : 55430-1411
Country : US
Telephone Number : 763-560-4860
Fax Number : 763-503-1430
Provider Business Practice Location Address
First Line : 6860 SHINGLE CREEK PKWY
Second Line : SUITE 116
City : BROOKLYN CENTER
State : MN
Zip : 55430-1411
Country : US
Telephone Number : 763-560-4860
Fax Number : 763-503-1430
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/13/2006
Last Update Date : 07/08/2007

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