Provider Demographics
NPI:1336297449
Name:GOLDBERG, BRUCE EDWARD (MSW)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:EDWARD
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33975 DEQUINDRE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-4649
Mailing Address - Country:US
Mailing Address - Phone:248-421-0717
Mailing Address - Fax:
Practice Address - Street 1:33975 DEQUINDRE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-4649
Practice Address - Country:US
Practice Address - Phone:248-421-0717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801069734101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health