Provider Demographics
NPI:1407609530
Name:GOLDSTICK, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:GOLDSTICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 ADANSON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-1317
Mailing Address - Country:US
Mailing Address - Phone:407-875-3700
Mailing Address - Fax:
Practice Address - Street 1:351 S BAY AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-2140
Practice Address - Country:US
Practice Address - Phone:407-321-3154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM101413171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator