Provider Demographics
NPI:1912264714
Name:GOLDBERG, ELLIOT E
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:E
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1637 CALIFORNIA AVE SW APT 4
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-1654
Mailing Address - Country:US
Mailing Address - Phone:206-545-2818
Mailing Address - Fax:
Practice Address - Street 1:1637 CALIFORNIA AVE SW APT 4
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-1654
Practice Address - Country:US
Practice Address - Phone:206-545-2818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000063781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW00006378OtherCREDENTIAL NUMBER