Provider Demographics
NPI:1942644935
Name:GOLDBERG, ELLEN E (MSW, CSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:E
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 E BRYAN AVE # A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2507
Mailing Address - Country:US
Mailing Address - Phone:801-209-2228
Mailing Address - Fax:
Practice Address - Street 1:155 S 300 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1217
Practice Address - Country:US
Practice Address - Phone:801-467-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8528436-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker