Provider Demographics
NPI:1164551453
Name:GOLDBERG, ILENE M (OT)
Entity Type:Individual
Prefix:MS
First Name:ILENE
Middle Name:M
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 LITTLE TOR ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956
Mailing Address - Country:US
Mailing Address - Phone:845-708-2000
Mailing Address - Fax:
Practice Address - Street 1:260 N LITTLE TOR RD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-2627
Practice Address - Country:US
Practice Address - Phone:845-708-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007890-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist