=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629169131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN FAYE GOLDNER LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 08/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5866 SHADOWLAWN DR
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48823-2340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-282-0524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48854-0010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-676-9788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 6801064637
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------