Provider Demographics
NPI:1497377378
Name:GOLDENBERG, IDELL (PSYD)
Entity Type:Individual
Prefix:
First Name:IDELL
Middle Name:
Last Name:GOLDENBERG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 SUDBURY ST
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-6748
Mailing Address - Country:US
Mailing Address - Phone:508-878-3054
Mailing Address - Fax:
Practice Address - Street 1:98 SUDBURY ST
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-6748
Practice Address - Country:US
Practice Address - Phone:508-878-3054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6935-103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist