Provider Demographics
NPI:1598865354
Name:GOLDENBERG, CHERYL (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:GOLDENBERG
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE
Mailing Address - Street 2:MS: 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-541-2500
Mailing Address - Fax:952-541-2539
Practice Address - Street 1:5100 GAMBLE DR STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1582
Practice Address - Country:US
Practice Address - Phone:952-541-2500
Practice Address - Fax:952-541-2539
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4072103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN518514900Medicaid