Healthcare Provider Details

I. General information

NPI: 1154659878
Provider Name (Legal Business Name): MRS. TERESIA GOLDBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 BROADWAY 601 A
NEW YORK NY
10032-1559
US

IV. Provider business mailing address

3959 BROADWAY 601 A
NEW YORK NY
10032-1559
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-5717
  • Fax: 212-304-5699
Mailing address:
  • Phone: 212-305-5717
  • Fax: 212-304-5699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: