Basic Information
| Provider Information | |||||||||
| NPI: | 1306373527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | SVETLANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KLICHEVSKI | ||||||||
| OtherFirstName: | SVETLANA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 920 ELKRIDGE LANDING RD | ||||||||
| Address2: | |||||||||
| City: | LINTHICUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210902917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434625010 | ||||||||
| FaxNumber: | 4106842031 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 KERNAN DR | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212076665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104486356 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2017 | ||||||||
| LastUpdateDate: | 07/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0808X | R114795 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health |
No ID Information.