Provider Demographics
NPI:1720108962
Name:GOLDBERG, STEPHEN ALAN (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ALAN
Last Name:GOLDBERG
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 1:220 WARING RD
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-2125
Mailing Address - Country:US
Mailing Address - Phone:215-635-3448
Mailing Address - Fax:215-635-3448
Practice Address - Street 1:8018 BUSTLETON AVE.
Practice Address - Street 2:2ND FLR.
Practice Address - City:PHILA.
Practice Address - State:PA
Practice Address - Zip Code:19152-2802
Practice Address - Country:US
Practice Address - Phone:215-742-6773
Practice Address - Fax:215-742-5829
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003906-L103TC0700X
NJSI02393103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA122950Medicare ID - Type Unspecified
PAR06190Medicare UPIN