1457484818 NPI number — MS. SUZANNE SHRADER GOLDENBERG MSW, L.I.C.S.W

Table of content: MS. SUZANNE SHRADER GOLDENBERG MSW, L.I.C.S.W (NPI 1457484818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457484818 NPI number — MS. SUZANNE SHRADER GOLDENBERG MSW, L.I.C.S.W

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDENBERG
Provider First Name:
SUZANNE
Provider Middle Name:
SHRADER
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, L.I.C.S.W
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:
1457484818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1421 NARRAGANSETT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRANSTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02905-5140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-467-0765
Provider Business Mailing Address Fax Number:
401-467-0765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1421 NARRAGANSETT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRANSTON
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02905-5140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-467-0765
Provider Business Practice Location Address Fax Number:
401-467-0765
Provider Enumeration Date:
03/14/2007

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: 1041C0700X , with the licence number:  ISWO1549 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 27350-5 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: SG5134 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1038120 . This is a "BEACON HEALTH STATEGIES" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 411607 . This is a "BLUECHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".