Provider Demographics
NPI:1346417680
Name:GOLDBERG, LAWRENCE MARK
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:MARK
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1871 WENTWOOD COVE
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1808
Mailing Address - Country:US
Mailing Address - Phone:407-416-2523
Mailing Address - Fax:
Practice Address - Street 1:1871 WENTWOOD COVE
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1808
Practice Address - Country:US
Practice Address - Phone:407-416-2523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW40531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical