Provider Demographics
NPI:1447485099
Name:GOLDBACH, MELISSA W (LICSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:W
Last Name:GOLDBACH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 LONG POND RD , UNIT #4
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2664
Mailing Address - Country:US
Mailing Address - Phone:774-269-9143
Mailing Address - Fax:508-746-2190
Practice Address - Street 1:124 LONG POND RD, UNIT #4
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2664
Practice Address - Country:US
Practice Address - Phone:508-747-0576
Practice Address - Fax:508-746-2190
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1080011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP2279301Medicare Oscar/Certification