Provider Demographics
NPI:1558043737
Name:GOLDBERG, SOPHIE JENNA (OTD, OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:SOPHIE
Middle Name:JENNA
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 AUDUBON PL
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3521
Mailing Address - Country:US
Mailing Address - Phone:201-693-3211
Mailing Address - Fax:
Practice Address - Street 1:30 W END AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7809
Practice Address - Country:US
Practice Address - Phone:718-608-9170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028085225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist