Provider Demographics
NPI:1417009697
Name:GOLDBERG, DAVID MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
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 1:34 SYCAMORE AVE
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:LITTLE SILVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07739-1228
Mailing Address - Country:US
Mailing Address - Phone:732-576-8925
Mailing Address - Fax:732-576-8814
Practice Address - Street 1:34 SYCAMORE AVE
Practice Address - Street 2:BUILDING 2
Practice Address - City:LITTLE SILVER
Practice Address - State:NJ
Practice Address - Zip Code:07739-1228
Practice Address - Country:US
Practice Address - Phone:732-576-8925
Practice Address - Fax:732-576-8814
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSI3454103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJGO662305Medicare ID - Type Unspecified