Provider Demographics
NPI:1770069882
Name:GOLDMAN, LAUREN ASHLEY
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 TIMACUAN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2254
Mailing Address - Country:US
Mailing Address - Phone:407-446-0856
Mailing Address - Fax:
Practice Address - Street 1:2100 N ALAFAYA TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4710
Practice Address - Country:US
Practice Address - Phone:407-720-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid