Provider Demographics
NPI:1902854797
Name:GOLDBERG, PENNY LAUREN (PT, ATC)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:LAUREN
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 W NEWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2249
Mailing Address - Country:US
Mailing Address - Phone:352-264-2499
Mailing Address - Fax:352-373-2544
Practice Address - Street 1:4035 NW 43RD ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-4598
Practice Address - Country:US
Practice Address - Phone:352-692-2135
Practice Address - Fax:352-373-2544
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
FLPT 28563225100000X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports