Basic Information
| Provider Information | |||||||||
| NPI: | 1962987925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDFEDER | ||||||||
| FirstName: | TANIA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOLDFEDER | ||||||||
| OtherFirstName: | TANIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1637 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423021637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706896500 | ||||||||
| FaxNumber: | 2706896677 | ||||||||
| Practice Location | |||||||||
| Address1: | NEW MEXICO SOLUTIONS | ||||||||
| Address2: | 707 BROADWAY NE SUITE 500 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052680701 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2018 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 10462 | NM | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | M-10462 | NM | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | C-11554 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.