Provider Demographics
NPI:1275505075
Name:GOLDBERG, PENNY J (MSS LCSW)
Entity type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:J
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MSS LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 PRESCOTT RD
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1041
Mailing Address - Country:US
Mailing Address - Phone:610-667-0112
Mailing Address - Fax:484-615-6080
Practice Address - Street 1:508 PRESCOTT RD
Practice Address - Street 2:
Practice Address - City:MERION STATION
Practice Address - State:PA
Practice Address - Zip Code:19066-1041
Practice Address - Country:US
Practice Address - Phone:610-667-0112
Practice Address - Fax:484-615-6080
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0136331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA742870OtherPART B NON-PHYSICIAN SPECIALTIES
PA742870Medicare ID - Type UnspecifiedMEDICARE