Provider Demographics
NPI:1417203241
Name:GOLDBERG, ANNIE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 SHEPARD CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2715
Mailing Address - Country:US
Mailing Address - Phone:312-802-0967
Mailing Address - Fax:
Practice Address - Street 1:1308 WAUKEGAN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-3070
Practice Address - Country:US
Practice Address - Phone:877-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2021-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst