Provider Demographics
NPI:1467639476
Name:GOLDBERG, STEPHANIE L (LCSW-R)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:303 5TH AVE
Mailing Address - Street 2:SUITE 1608
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6601
Mailing Address - Country:US
Mailing Address - Phone:646-481-8371
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE
Practice Address - Street 2:SUITE 1608
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6601
Practice Address - Country:US
Practice Address - Phone:646-481-8371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074884-1104100000X
NY0782701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker