Provider Demographics
NPI:1669815619
Name:GOLDBERG, ILANA LESSER (MA)
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:LESSER
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:ILANA
Other - Middle Name:
Other - Last Name:LESSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 MERCER ST
Mailing Address - Street 2:APT. 31B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-6724
Mailing Address - Country:US
Mailing Address - Phone:646-335-3055
Mailing Address - Fax:
Practice Address - Street 1:300 MERCER ST
Practice Address - Street 2:APT. 31B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6724
Practice Address - Country:US
Practice Address - Phone:646-335-3055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY840271174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist