Provider Demographics
NPI:1194128470
Name:GOLDBERG, CANDICE HAYDEN
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:HAYDEN
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2138
Mailing Address - Country:US
Mailing Address - Phone:502-510-2972
Mailing Address - Fax:
Practice Address - Street 1:1900 SILS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-2138
Practice Address - Country:US
Practice Address - Phone:502-510-2972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1762133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered