Provider Demographics
NPI:1417081811
Name:GOLDBERG, MARLENE RUTH (IMFT)
Entity Type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:RUTH
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:IMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 HORNBLEND ST
Mailing Address - Street 2:#3
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-2950
Mailing Address - Country:US
Mailing Address - Phone:732-616-4963
Mailing Address - Fax:
Practice Address - Street 1:800 NATIONAL CITY BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-3202
Practice Address - Country:US
Practice Address - Phone:619-336-1964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49827106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8729OtherUBH PROVIDEBILLING NUMBER