Provider Demographics
NPI:1164996450
Name:GOLDMAN, KIMBERLY SARAH
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SARAH
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 UNDERHILL AVE
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-5017
Mailing Address - Country:US
Mailing Address - Phone:347-306-4806
Mailing Address - Fax:
Practice Address - Street 1:11 UNDERHILL AVE
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-5017
Practice Address - Country:US
Practice Address - Phone:347-306-4806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY855281103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool