Provider Demographics
NPI:1447740725
Name:GOLDSTEIN, DESIREE ROSE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:ROSE
Last Name:GOLDSTEIN
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 1:100 GARDEN DR APT K252
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5991
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 IRVIN AVE SW
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-2214
Practice Address - Country:US
Practice Address - Phone:678-523-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-13
Last Update Date:2018-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty