1558043737 NPI number — MISS SOPHIE JENNA GOLDBERG OTD, OTR/L

Table of content: JUAN QU O.D. (NPI 1104206861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558043737 NPI number — MISS SOPHIE JENNA GOLDBERG OTD, OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDBERG
Provider First Name:
SOPHIE
Provider Middle Name:
JENNA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
OTD, OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558043737
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 AUDUBON PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIR LAWN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07410-3521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-693-3211
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 W END AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10023-7809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-608-9170
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  028085 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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