Healthcare Provider Details

I. General information

NPI: 1902854797
Provider Name (Legal Business Name): PENNY LAUREN GOLDBERG PT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 NW 43RD ST
GAINESVILLE FL
32606-4598
US

IV. Provider business mailing address

4820 W NEWBERRY RD
GAINESVILLE FL
32607-2249
US

V. Phone/Fax

Practice location:
  • Phone: 352-692-2135
  • Fax: 352-373-2544
Mailing address:
  • Phone: 352-264-2499
  • Fax: 352-373-2544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 28563
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT 28563
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: