Provider Demographics
NPI:1982784427
Name:KELLBERG-GOLDSTEIN, EVA HARRIETTE (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:EVA
Middle Name:HARRIETTE
Last Name:KELLBERG-GOLDSTEIN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:EVA
Other - Middle Name:
Other - Last Name:KJELLBERG-GOLDSTEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:FEGS 9745 QUEENS BOULVARD
Mailing Address - Street 2:PENTHOUSE FLOOR
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2116
Mailing Address - Country:US
Mailing Address - Phone:718-896-9090
Mailing Address - Fax:718-830-0724
Practice Address - Street 1:FEGS 9745 QUEENS BOULVARD
Practice Address - Street 2:PENT HOUSE FLOOR
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2116
Practice Address - Country:US
Practice Address - Phone:718-896-9090
Practice Address - Fax:718-830-0724
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO46277-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN5M893Medicare UPIN