Provider Demographics
NPI:1487091948
Name:GOLDBACH, LAUREN GLORIA (LCSW)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:GLORIA
Last Name:GOLDBACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAURRN
Other - Middle Name:G
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1400 E SOUTHERN AVE
Mailing Address - Street 2:STE. 735
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5691
Mailing Address - Country:US
Mailing Address - Phone:480-804-0326
Mailing Address - Fax:480-804-0083
Practice Address - Street 1:2120 S MCCLINTOCK DR
Practice Address - Street 2:STE. 105
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2692
Practice Address - Country:US
Practice Address - Phone:480-804-0326
Practice Address - Fax:480-804-0083
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-13735104100000X
AZLCSW-160341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ124988Medicaid
AZZ187413Medicare PIN