Provider Demographics
NPI:1346417680
Name:GOLDBERG, LAWRENCE MARK (LCSW)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:MARK
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 COLUMBIA ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1133
Mailing Address - Country:US
Mailing Address - Phone:407-262-2220
Mailing Address - Fax:407-834-5011
Practice Address - Street 1:21 COLUMBIA ST STE 201
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1133
Practice Address - Country:US
Practice Address - Phone:407-262-2220
Practice Address - Fax:407-834-5011
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW40531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117630100Medicaid