Provider Demographics
NPI:1952774341
Name:GOLDBERG, LEAH (RD)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 N RUTLEDGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-3721
Mailing Address - Country:US
Mailing Address - Phone:217-788-3948
Mailing Address - Fax:
Practice Address - Street 1:932 N RUTLEDGE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3721
Practice Address - Country:US
Practice Address - Phone:217-788-3948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006626133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered