Provider Demographics
NPI:1053688358
Name:GOLDBERG, TIMOTHY SCOTT (PT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:SCOTT
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27306 VIA OLMO
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691
Mailing Address - Country:US
Mailing Address - Phone:858-775-5383
Mailing Address - Fax:
Practice Address - Street 1:200 S MANCHESTER AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-456-5571
Practice Address - Fax:714-456-5627
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28074225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic