Provider Demographics
NPI:1356064489
Name:GOLDBERG, LISA MALLENBAUM (LPC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MALLENBAUM
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 OREMS LN
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-4022
Mailing Address - Country:US
Mailing Address - Phone:203-858-4808
Mailing Address - Fax:
Practice Address - Street 1:489 POST RD E
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4435
Practice Address - Country:US
Practice Address - Phone:203-493-1151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5790101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional