Provider Demographics
NPI:1639734734
Name:GOLDMAN, ELAINA BETH (MS, OTR)
Entity Type:Individual
Prefix:
First Name:ELAINA
Middle Name:BETH
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:6925 PARKDALE PL
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-4673
Practice Address - Country:US
Practice Address - Phone:317-597-4553
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006269A225X00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300025502Medicaid
IN31006269AOtherINDIANA PROF LICENSING AGENCY - OCCUPATIONAL THERAPY COMMITTEE
376880OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY