Provider Demographics
NPI:1447479696
Name:GOLDBERG, LAURIE (MS, RD, CDN)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 GOODRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-2912
Mailing Address - Country:US
Mailing Address - Phone:718-884-1750
Mailing Address - Fax:
Practice Address - Street 1:110 E 59TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1304
Practice Address - Country:US
Practice Address - Phone:917-834-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005233133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered