Provider Demographics
NPI:1366486219
Name:GOLDBERG, ROSEANNE (RPT)
Entity Type:Individual
Prefix:
First Name:ROSEANNE
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1326
Mailing Address - Country:US
Mailing Address - Phone:203-732-1580
Mailing Address - Fax:203-732-1576
Practice Address - Street 1:130 DIVISION ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1326
Practice Address - Country:US
Practice Address - Phone:203-732-1580
Practice Address - Fax:203-732-1576
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00424281400OtherBLUECARE FAMILY PLAN
CT659984OtherCONNECTICARE
CT080001632CT01OtherBLUE CROSS BLUE SHIELD
CT2V3989OtherHEALTHNET
CT7710575OtherAETNA
CTA752119OtherOXFORD