Provider Demographics
NPI:1689082117
Name:GOLDBERG, MIRIAM (LCSW, CAMS-II)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:LCSW, CAMS-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 UPPER ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-4337
Mailing Address - Country:US
Mailing Address - Phone:808-651-6278
Mailing Address - Fax:808-356-0634
Practice Address - Street 1:3422 UPPER ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-4337
Practice Address - Country:US
Practice Address - Phone:808-651-6278
Practice Address - Fax:808-356-0634
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI40351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000390294OtherHMSA PROVIDER #
HI818388Medicaid
HI1932625902OtherNPI 2
HIU070996OtherUPIN
HIGE-005-883-5968-01OtherGENERAL EXCISE