Provider Demographics
NPI:1437190642
Name:GOLDBERG, JUDITH FREYA (PHD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:FREYA
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 MAIN ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1961
Mailing Address - Country:US
Mailing Address - Phone:781-721-0663
Mailing Address - Fax:781-729-3210
Practice Address - Street 1:955 MAIN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1961
Practice Address - Country:US
Practice Address - Phone:781-721-0663
Practice Address - Fax:781-729-3210
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1533103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA154168OtherMAGELLAN
MA154168OtherMAGELLAN