Provider Demographics
NPI:1164575742
Name:GOLDBERG, JONATHAN EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EDWARD
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 1:35 WALDEN ST
Mailing Address - Street 2:APT 3F
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2047
Mailing Address - Country:US
Mailing Address - Phone:617-576-0875
Mailing Address - Fax:
Practice Address - Street 1:875 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE #84
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3067
Practice Address - Country:US
Practice Address - Phone:617-928-8891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8500103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06448OtherBCBSMA
MAW06448OtherBCBSMA