Provider Demographics
NPI:1063234847
Name:GOLDBERG, JILLIAN (OTR)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MAYBROOK RD STE N
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL HALL
Mailing Address - State:NY
Mailing Address - Zip Code:10916-2741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:NEW FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06812-4024
Practice Address - Country:US
Practice Address - Phone:203-312-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6511225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist