Provider Demographics
NPI:1598792905
Name:GOLDBERG, ALAN (PHD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JEFFERSON ST.
Mailing Address - Street 2:STE. 2C
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24509
Mailing Address - Country:US
Mailing Address - Phone:617-379-0496
Mailing Address - Fax:617-807-0958
Practice Address - Street 1:1518 WALNUT ST.
Practice Address - Street 2:STE. 804
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102
Practice Address - Country:US
Practice Address - Phone:215-399-9764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004179L103T00000X
PAPS.004179-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist