Provider Demographics
NPI:1437183282
Name:GOLDBERG, HARRY DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:DAVID
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 1:13263 VENTURA BLVD
Mailing Address - Street 2:#2
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-1839
Mailing Address - Country:US
Mailing Address - Phone:818-501-6090
Mailing Address - Fax:818-501-6095
Practice Address - Street 1:12220 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342
Practice Address - Country:US
Practice Address - Phone:626-357-3207
Practice Address - Fax:626-301-9590
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY091810103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY91810Medicaid
CAPSY91810Medicaid
R33634Medicare UPIN