Provider Demographics
NPI:1275860181
Name:GOLDBERG, BRETT RANDOLPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:RANDOLPH
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 1:230 MIDDLE NECK RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1113
Mailing Address - Country:US
Mailing Address - Phone:516-466-6440
Mailing Address - Fax:516-466-6441
Practice Address - Street 1:230 MIDDLE NECK RD
Practice Address - Street 2:SUITE 3
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-1113
Practice Address - Country:US
Practice Address - Phone:516-466-6440
Practice Address - Fax:516-466-6441
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016396103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical