Healthcare Provider Details

I. General information

NPI: 1104111814
Provider Name (Legal Business Name): ANNE REBECCA GOODMAN RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 STERLING PL
BROOKLYN NY
11216-3903
US

IV. Provider business mailing address

922 PRESIDENT ST
BROOKLYN NY
11215-1695
US

V. Phone/Fax

Practice location:
  • Phone: 718-804-0900
  • Fax:
Mailing address:
  • Phone: 718-399-2128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number005971-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: