Provider Demographics
NPI:1669549721
Name:GOLDBERG, SANDRA M (MS, RPT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MS, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 WALNUT ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2944
Mailing Address - Country:US
Mailing Address - Phone:215-563-0114
Mailing Address - Fax:215-563-0567
Practice Address - Street 1:1601 WALNUT ST
Practice Address - Street 2:SUITE 208
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-2944
Practice Address - Country:US
Practice Address - Phone:215-563-0114
Practice Address - Fax:215-563-0567
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA225100000X225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG070581Medicare ID - Type Unspecified