Provider Demographics
NPI:1417106675
Name:GOLDENBERG, MATTHEW ETHAN (PSY D)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ETHAN
Last Name:GOLDENBERG
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:111 TUMWATER BLVD SE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501
Mailing Address - Country:US
Mailing Address - Phone:206-395-9193
Mailing Address - Fax:360-464-2720
Practice Address - Street 1:111 TUMWATER BLVD SE
Practice Address - Street 2:SUITE 210
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501
Practice Address - Country:US
Practice Address - Phone:206-395-9193
Practice Address - Fax:360-464-2720
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH6039598103T00000X, 103T00000X
WAPY60416098103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist