Provider Demographics
NPI:1649656554
Name:GOLDBERG, INNA (LICSW)
Entity type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HOSMER ST
Mailing Address - Street 2:UNIT 3
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1977
Mailing Address - Country:US
Mailing Address - Phone:347-277-9091
Mailing Address - Fax:
Practice Address - Street 1:415 SOUTH ST
Practice Address - Street 2:MS061
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2728
Practice Address - Country:US
Practice Address - Phone:781-736-2222
Practice Address - Fax:781-736-3731
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0001203561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical