Healthcare Provider Details

I. General information

NPI: 1447246848
Provider Name (Legal Business Name): MELISSA JILL GOLDMAN L.C.S.W.-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 04/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2277 GRAND AVE
BALDWIN NY
11510-3148
US

IV. Provider business mailing address

217 N. MAPLE STREET
MASSAPEQUA NY
11758
US

V. Phone/Fax

Practice location:
  • Phone: 516-546-6924
  • Fax:
Mailing address:
  • Phone: 516-524-7076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number069612-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: