=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053810531
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEAH GOLDENBERG MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2018
-----------------------------------------------------
Last Update Date | 02/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 886 RIVER AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-5282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-968-2041
-----------------------------------------------------
Fax | 917-968-2041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 JOHN ST
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-4268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 41YS00930800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------