Provider Demographics
NPI:1235468927
Name:GOLDBERG, STACY (MPH, RN, BSN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MPH, RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 250042
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325-0042
Mailing Address - Country:US
Mailing Address - Phone:248-563-2920
Mailing Address - Fax:248-862-2022
Practice Address - Street 1:1627 W BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3501
Practice Address - Country:US
Practice Address - Phone:248-563-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704212928163WN1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN1003XNursing Service ProvidersRegistered NurseNutrition Support