Healthcare Provider Details

I. General information

NPI: 1306070412
Provider Name (Legal Business Name): GOLDIE RABAEV LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 AUER CT SUIT D
EAST BRUNSWICK NJ
08816-5828
US

IV. Provider business mailing address

6 AUER CT SUIT D
EAST BRUNSWICK NJ
08816-5828
US

V. Phone/Fax

Practice location:
  • Phone: 937-964-5779
  • Fax: 732-390-0017
Mailing address:
  • Phone: 937-964-5779
  • Fax: 732-390-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number002598
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00394000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: