Provider Demographics
NPI:1699163410
Name:GOLDBERG, DANIEL ARON (PSYD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ARON
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 AUTUMN BLVD
Mailing Address - Street 2:UNIT 102
Mailing Address - City:LAKEMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60051-6690
Mailing Address - Country:US
Mailing Address - Phone:630-251-8762
Mailing Address - Fax:
Practice Address - Street 1:600 WEST GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046
Practice Address - Country:US
Practice Address - Phone:847-245-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008898103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical