Provider Demographics
NPI:1518338607
Name:GOLDBERG, KIRBY
Entity Type:Individual
Prefix:MISS
First Name:KIRBY
Middle Name:
Last Name:GOLDBERG
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 1:3 GAME LN
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3411
Mailing Address - Country:US
Mailing Address - Phone:631-365-9776
Mailing Address - Fax:
Practice Address - Street 1:142-02 20TH AVENUE
Practice Address - Street 2:THE PEDERSON-KRAG CENTER
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11351
Practice Address - Country:US
Practice Address - Phone:718-559-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY512866126390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program