Provider Demographics
NPI:1104033554
Name:GOLDBERG, WARREN (PHD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:
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:PO BOX 482
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-0482
Mailing Address - Country:US
Mailing Address - Phone:917-952-0942
Mailing Address - Fax:
Practice Address - Street 1:1472 MOFFITT AVE
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1516
Practice Address - Country:US
Practice Address - Phone:917-952-0942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010735103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS1-0735-9OtherWCB
NYS1-0735-9OtherWCB