=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376618488
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JO ANNE GOLDMAN MSW LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2006
-----------------------------------------------------
Last Update Date | 11/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 84 HIGH STREET
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-391-6222
-----------------------------------------------------
Fax | 797-391-6119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84 HIGH STREET
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-391-6222
-----------------------------------------------------
Fax | 781-391-6119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1018384
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------