Provider Demographics
NPI:1518997634
Name:GOLDMAN, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:GOLDMAN
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 1:209 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3763
Mailing Address - Country:US
Mailing Address - Phone:401-272-1528
Mailing Address - Fax:
Practice Address - Street 1:261 WICKENDEN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4422
Practice Address - Country:US
Practice Address - Phone:401-272-1528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW003841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI30694-4OtherBLUE CROSS
RI62-15758OtherUNITED BEHAVIORAL HEALTH
RI406425OtherBLUE CHIP