Provider Demographics
NPI:1710209754
Name:GOLDBERG, ILYSE SARAH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ILYSE
Middle Name:SARAH
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6363 SAINT CHARLES AVE
Mailing Address - Street 2:CAMPUS BOX 200
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-6143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6363 SAINT CHARLES AVE
Practice Address - Street 2:CAMPUS BOX 200
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-6143
Practice Address - Country:US
Practice Address - Phone:504-865-3835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA92351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical