Provider Demographics
NPI:1790902500
Name:GOLDBERG, KATIE E (MPT, DPT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:E
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MPT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5089
Practice Address - Country:US
Practice Address - Phone:781-321-2727
Practice Address - Fax:781-321-4995
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15813225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY69555Medicare ID - Type Unspecified