Provider Demographics
NPI:1700100708
Name:GOLDENBERG, DERYL (PHD)
Entity type:Individual
Prefix:
First Name:DERYL
Middle Name:
Last Name:GOLDENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16530 VENTURA BLVD
Mailing Address - Street 2:STE. 501
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4554
Mailing Address - Country:US
Mailing Address - Phone:818-386-1094
Mailing Address - Fax:818-386-1182
Practice Address - Street 1:16530 VENTURA BLVD
Practice Address - Street 2:STE. 501
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4554
Practice Address - Country:US
Practice Address - Phone:818-386-1094
Practice Address - Fax:818-386-1182
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15273103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical