=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023402047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NANCY H. GOLDMAN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2015
-----------------------------------------------------
Last Update Date | 03/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 OLD CANTON RD SUITE 465
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-946-7482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3000 OLD CANTON RD SUITE 465
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-946-7482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MRS. NANCY H GOLDMAN
-----------------------------------------------------
Credential | PMHCNS,BC
-----------------------------------------------------
Telephone | 601-946-7482
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | R624144
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------