Provider Demographics
NPI:1649868118
Name:GOLDFEDER, SHANE ARI (BSN, RN)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:ARI
Last Name:GOLDFEDER
Suffix:
Gender:M
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 NE 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-3207
Mailing Address - Country:US
Mailing Address - Phone:561-932-8558
Mailing Address - Fax:
Practice Address - Street 1:711 NE 8TH AVE
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-3207
Practice Address - Country:US
Practice Address - Phone:561-932-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0381OtherN/A