Provider Demographics
NPI:1750403119
Name:GOLDBERG, PHYLLIS (PHD)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18757 BURBANK BLVD
Mailing Address - Street 2:#125
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3375
Mailing Address - Country:US
Mailing Address - Phone:818-773-7795
Mailing Address - Fax:310-821-1916
Practice Address - Street 1:18757 BURBANK BLVD
Practice Address - Street 2:#125
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3375
Practice Address - Country:US
Practice Address - Phone:818-773-7795
Practice Address - Fax:310-821-1916
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT16868106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist