Provider Demographics
NPI:1093798936
Name:GOLDBERG, GLENN MARSHALL (PHD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:MARSHALL
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ST. JOHNS MEDICAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:904-797-2705
Mailing Address - Fax:904-797-2820
Practice Address - Street 1:9 ST. JOHNS MEDICAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-797-2705
Practice Address - Fax:904-797-2820
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002028103TC0700X
FLPY 7295103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OTHMedicare UPIN