Provider Demographics
NPI:1912105289
Name:GOLDBERG, SUSAN SAGMAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:SAGMAN
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7937 LA MIRADA DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-6107
Mailing Address - Country:US
Mailing Address - Phone:561-929-0996
Mailing Address - Fax:
Practice Address - Street 1:7937 LA MIRADA DR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-6107
Practice Address - Country:US
Practice Address - Phone:561-929-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW34611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8118515 00Medicaid