Provider Demographics
NPI:1962925651
Name:GOLDBERG, KEVIN J (PSYD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
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 1:1 E SUPERIOR ST STE 506
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2593
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 E 7TH ST STE 620
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:877-515-7147
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37938103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist