Provider Demographics
NPI:1689918146
Name:GOLDBERG, BRIAN (PSYD, BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PSYD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 COMMACK RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-6021
Mailing Address - Country:US
Mailing Address - Phone:516-848-8551
Mailing Address - Fax:
Practice Address - Street 1:283 COMMACK RD
Practice Address - Street 2:SUITE 205
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-6021
Practice Address - Country:US
Practice Address - Phone:516-848-8551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017826103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities