Provider Demographics
NPI:1710312780
Name:GOLDBACH, PENELOPE (LSW)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:
Last Name:GOLDBACH
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 S MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-4146
Mailing Address - Country:US
Mailing Address - Phone:724-550-4343
Mailing Address - Fax:724-550-4311
Practice Address - Street 1:253 S MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-4146
Practice Address - Country:US
Practice Address - Phone:724-550-4343
Practice Address - Fax:724-550-4311
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW128854101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASW128854OtherPA DOS