Provider Demographics
NPI:1740372515
Name:GOMBERG, DAVID STUART (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:STUART
Last Name:GOMBERG
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 1:169 MAPLEWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040
Mailing Address - Country:US
Mailing Address - Phone:973-313-9289
Mailing Address - Fax:973-763-5604
Practice Address - Street 1:169 MAPLEWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040
Practice Address - Country:US
Practice Address - Phone:973-313-9289
Practice Address - Fax:973-763-5604
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3703103T00000X
NY0130661103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist