Provider Demographics
NPI:1144877895
Name:GOLDMAN, KISSEL
Entity type:Individual
Prefix:
First Name:KISSEL
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8777 SAN JOSE BLVD STE 801
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4291
Mailing Address - Country:US
Mailing Address - Phone:904-374-6403
Mailing Address - Fax:
Practice Address - Street 1:8777 SAN JOSE BLVD STE 801
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4291
Practice Address - Country:US
Practice Address - Phone:904-374-6403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-21-47979103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician