Provider Demographics
NPI:1770992547
Name:GOLDBERG, KENNETH (PHD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
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:PO BOX 3702
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-0569
Mailing Address - Country:US
Mailing Address - Phone:856-547-4000
Mailing Address - Fax:
Practice Address - Street 1:215 HIGHLAND AVE
Practice Address - Street 2:SUITE C
Practice Address - City:HADDON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08108-2634
Practice Address - Country:US
Practice Address - Phone:856-547-4000
Practice Address - Fax:856-547-1118
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2258103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical