Provider Demographics
NPI:1417396367
Name:GOLDBERG, KELLY NICOLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 WALLINGTON WAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MARRIOTTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21104-1505
Mailing Address - Country:US
Mailing Address - Phone:410-442-9791
Mailing Address - Fax:
Practice Address - Street 1:2500 WALLINGTON WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:MARRIOTTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21104-1505
Practice Address - Country:US
Practice Address - Phone:410-442-9791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06454235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist