Provider Demographics
NPI:1619144847
Name:GOLDBERG, DOROTHY IDA
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:IDA
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEVORAH
Other - Middle Name:IDA
Other - Last Name:GOLDBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1204 VICENTE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116
Mailing Address - Country:US
Mailing Address - Phone:415-333-4055
Mailing Address - Fax:
Practice Address - Street 1:1204 VICENTE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116
Practice Address - Country:US
Practice Address - Phone:415-333-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW76461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCSW4676OtherCALIF BOARD OF BEHAV SCIENCES