Provider Demographics
NPI:1528569423
Name:GOLDBERG, BENJAMIN WILLIS
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WILLIS
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:TYLER HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18469-0003
Mailing Address - Country:US
Mailing Address - Phone:570-224-0052
Mailing Address - Fax:
Practice Address - Street 1:1046 COCHECTON TPKE
Practice Address - Street 2:
Practice Address - City:TYLER HILL
Practice Address - State:PA
Practice Address - Zip Code:18469-4010
Practice Address - Country:US
Practice Address - Phone:570-224-0052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist