Provider Demographics
NPI:1801007521
Name:GOLDBERG, LISA SISK (EDS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:SISK
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:SISK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS
Mailing Address - Street 1:1010 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-5813
Mailing Address - Country:US
Mailing Address - Phone:520-225-6410
Mailing Address - Fax:520-225-6170
Practice Address - Street 1:1010 E 10TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-5813
Practice Address - Country:US
Practice Address - Phone:520-225-6410
Practice Address - Fax:520-225-6170
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ595085Medicaid