Provider Demographics
NPI:1821264961
Name:GOLDBERG, MARK (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 SWAYZE ST
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2025
Mailing Address - Country:US
Mailing Address - Phone:973-736-3655
Mailing Address - Fax:
Practice Address - Street 1:27 SWAYZE ST
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2025
Practice Address - Country:US
Practice Address - Phone:973-736-3655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC052400001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical