Provider Demographics
NPI:1457627127
Name:GOLDBERG, SHIRA (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 CROWN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-5304
Mailing Address - Country:US
Mailing Address - Phone:917-971-8529
Mailing Address - Fax:
Practice Address - Street 1:750 JENNINGS ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-1204
Practice Address - Country:US
Practice Address - Phone:718-378-0006
Practice Address - Fax:718-589-9544
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63016683225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist