Provider Demographics
NPI:1164911871
Name:GOLDBERG, SAMIRA (MA)
Entity Type:Individual
Prefix:
First Name:SAMIRA
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SAMIRA
Other - Middle Name:
Other - Last Name:NAHAMOO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18 PINE DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2830
Mailing Address - Country:US
Mailing Address - Phone:914-262-9304
Mailing Address - Fax:
Practice Address - Street 1:7000 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1022
Practice Address - Country:US
Practice Address - Phone:914-262-9304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NY002393103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYZA48527JMedicaid