Provider Demographics
NPI:1639254469
Name:GOLDBERG, MYRON LEE
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:LEE
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 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF WASHINGTON MEDICAL CTR
Practice Address - Street 2:1959 NE PACIFIC ST
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-6157
Practice Address - Country:US
Practice Address - Phone:206-598-4295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001795103TC0700X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
3516OtherINTERNAL ID-MOTOR VEHICLE ID
WA8352270Medicaid
WAP00088051OtherRAIL ROAD MEDICARE
WA8352270Medicaid
WA8800273Medicare PIN
WAP00088051OtherRAIL ROAD MEDICARE