Provider Demographics
NPI:1235425117
Name:GOLDBERG, LISA ANN (COTA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7609 EDGEMONT RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45237-2607
Mailing Address - Country:US
Mailing Address - Phone:513-939-5342
Mailing Address - Fax:
Practice Address - Street 1:7609 EDGEMONT RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45237-2607
Practice Address - Country:US
Practice Address - Phone:513-939-5342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOTA-04159171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor