Provider Demographics
NPI:1972196947
Name:GOLDBERG, KENNETH J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
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 1:15431 PICKETT CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2427
Mailing Address - Country:US
Mailing Address - Phone:314-614-4393
Mailing Address - Fax:
Practice Address - Street 1:15431 PICKETT CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2427
Practice Address - Country:US
Practice Address - Phone:314-614-4393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0015071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical