Provider Demographics
NPI:1114945193
Name:GOLDBERG, MARY L (MS,RN,CS)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:L
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MS,RN,CS
Other - Prefix:
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Mailing Address - Street 1:53 LANGLEY RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:NEWTON CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1913
Mailing Address - Country:US
Mailing Address - Phone:617-671-1239
Mailing Address - Fax:617-671-1239
Practice Address - Street 1:53 LANGLEY RD
Practice Address - Street 2:SUITE 330
Practice Address - City:NEWTON CENTER
Practice Address - State:MA
Practice Address - Zip Code:02459-1913
Practice Address - Country:US
Practice Address - Phone:617-671-1239
Practice Address - Fax:617-671-1239
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA158556364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA458483OtherTUFTS
MAPN0833OtherBS/BS OF MASSACHUSETTS
MA458483OtherTUFTS
MAPN0833OtherBS/BS OF MASSACHUSETTS