Provider Demographics
NPI:1952890741
Name:GOLL, EDWARD (LMT, MLD)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:GOLL
Suffix:
Gender:M
Credentials:LMT, MLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 TECUMSEH ST.
Mailing Address - Street 2:APT, SUITE, BLDG. (OPTIONAL)
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906
Mailing Address - Country:US
Mailing Address - Phone:401-861-1070
Mailing Address - Fax:
Practice Address - Street 1:148 WATERMAN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2130
Practice Address - Country:US
Practice Address - Phone:401-861-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01564225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist