Provider Demographics
NPI:1609177203
Name:GOLDBERG, STACY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 MILL ST
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-3036
Mailing Address - Country:US
Mailing Address - Phone:614-414-0309
Mailing Address - Fax:
Practice Address - Street 1:170 MILL ST
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-3036
Practice Address - Country:US
Practice Address - Phone:614-414-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL007396235Z00000X
OHSP.10732235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist