Basic Information
| Provider Information | |||||||||
| NPI: | 1457776122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHAW | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | DENISE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5305 MOUNT VEEDER WAY | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327653424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548058820 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1809 E BROADWAY ST | ||||||||
| Address2: | #122 | ||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327658597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073595693 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
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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 | 235Z00000X | SZ6594 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.