Provider Demographics
NPI:1659597128
Name:GOLDBERG, DANIEL (MHRS)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 N PACIFIC AVE SPC 27
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2738
Mailing Address - Country:US
Mailing Address - Phone:831-426-0633
Mailing Address - Fax:
Practice Address - Street 1:303 POTRERO ST
Practice Address - Street 2:42-103
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2741
Practice Address - Country:US
Practice Address - Phone:831-466-9307
Practice Address - Fax:831-466-9748
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA44AVOtherMEDI-CAL PRV NBR