Provider Demographics
NPI:1376618488
Name:GOLDMAN, JO ANNE (MSW LICSW)
Entity Type:Individual
Prefix:MS
First Name:JO
Middle Name:ANNE
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155
Mailing Address - Country:US
Mailing Address - Phone:781-391-6222
Mailing Address - Fax:781-391-6119
Practice Address - Street 1:84 HIGH STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:787-391-6222
Practice Address - Fax:797-391-6119
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10183841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP05778OtherBC
937501OtherPACIFIC CARE
146334OtherMAGELLAN BEHAVIORAL HEALT
002273OtherVALUE OPTIONS
MA723059OtherTUFTS
937501OtherPACIFIC CARE