Provider Demographics
NPI:1376613091
Name:GOLDMAN, KATHY L (BA, AC-BC)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:L
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:BA, AC-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8820 SW 191ST ST
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-7143
Mailing Address - Country:US
Mailing Address - Phone:305-254-4969
Mailing Address - Fax:305-235-1733
Practice Address - Street 1:10300 SW 216TH ST
Practice Address - Street 2:8820 SW 191 STREET CUTLER BAY FLORIDA 33157
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33190-1003
Practice Address - Country:US
Practice Address - Phone:305-254-4969
Practice Address - Fax:305-235-1733
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0603031-01OtherCHI CASE MANAGER NUMBER
FL762004700Medicaid