Basic Information
| Provider Information | |||||||||
| NPI: | 1588983084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDSON | ||||||||
| FirstName: | HORACE | ||||||||
| MiddleName: | SOMMERVILLE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1034 GROVE PARK CIR | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334369436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615031139 | ||||||||
| FaxNumber: | 5617128070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1034 GROVE PARK CIR | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334369436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615031139 | ||||||||
| FaxNumber: | 5617128070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2010 | ||||||||
| LastUpdateDate: | 05/24/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | FL | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | HXZ440139708313 | 01 | FL | BLUECROSS BLUE SHIELD | OTHER |