Provider Demographics
NPI:1245413814
Name:GOLDBERG, CARLY L (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:L
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 E LANCASTER AVE
Mailing Address - Street 2:SUITE 15-G
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-1552
Mailing Address - Country:US
Mailing Address - Phone:610-930-3025
Mailing Address - Fax:
Practice Address - Street 1:1062 E LANCASTER AVE
Practice Address - Street 2:SUITE 15-G
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-1552
Practice Address - Country:US
Practice Address - Phone:610-930-3025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
PACW0164171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101492950 0001Medicaid