Healthcare Provider Details

I. General information

NPI: 1952774341
Provider Name (Legal Business Name): LEAH GOLDBERG R.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2015
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 N RUTLEDGE ST
SPRINGFIELD IL
62702-3721
US

IV. Provider business mailing address

932 N RUTLEDGE ST
SPRINGFIELD IL
62702-3721
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3948
  • Fax:
Mailing address:
  • Phone: 217-788-3948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164006626
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: