Provider Demographics
NPI:1932526282
Name:GOLDMAN, SUSAN (LATC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16190 ED WARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:MD
Mailing Address - Zip Code:21797-7812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8890 CENTRE PARK DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2188
Practice Address - Country:US
Practice Address - Phone:410-884-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA0000027172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker