Healthcare Provider Details

I. General information

NPI: 1346329638
Provider Name (Legal Business Name): WENDY G GOLDBERG MSN, APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 01/30/2021
Certification Date: 01/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

5615 SUTTERS LN
BLOOMFIELD HILLS MI
48301-1057
US

V. Phone/Fax

Practice location:
  • Phone: 313-556-8736
  • Fax: 313-879-1675
Mailing address:
  • Phone: 248-842-0158
  • Fax: 313-879-1675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704102520
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704102520
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: