Provider Demographics
NPI:1033252960
Name:GOLDBERG, CAROL GENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:GENE
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 754
Mailing Address - Street 2:40 QUEENS ST
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-0754
Mailing Address - Country:US
Mailing Address - Phone:516-364-5084
Mailing Address - Fax:
Practice Address - Street 1:3375 PARK AVE
Practice Address - Street 2:SUITE 4000
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793
Practice Address - Country:US
Practice Address - Phone:516-364-5084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3668103T00000X
FLPY0004115103T00000X
NJ1817103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02532685Medicaid
NY02532685Medicaid