Provider Demographics
NPI:1457776122
Name:GOLDBERG, KIMBERLY DENISE
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DENISE
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:DENISE
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5305 MOUNT VEEDER WAY
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-3424
Mailing Address - Country:US
Mailing Address - Phone:954-805-8820
Mailing Address - Fax:
Practice Address - Street 1:1809 E BROADWAY ST
Practice Address - Street 2:#122
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8597
Practice Address - Country:US
Practice Address - Phone:407-359-5693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6594235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist