Provider Demographics
NPI:1346329638
Name:GOLDBERG, WENDY G (MSN, APRN, BC)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:G
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MSN, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5615 SUTTERS LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1057
Mailing Address - Country:US
Mailing Address - Phone:248-842-0158
Mailing Address - Fax:313-879-1675
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-556-8736
Practice Address - Fax:313-879-1675
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704102520163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse