Provider Demographics
NPI:1417133778
Name:GOLDBERG, PHYLLIS K (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:K
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12351 SW 71ST CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5451
Mailing Address - Country:US
Mailing Address - Phone:305-661-1761
Mailing Address - Fax:
Practice Address - Street 1:12351 SW 71ST CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-5451
Practice Address - Country:US
Practice Address - Phone:305-661-1761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 1197235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist