MEDICARE: DR. CORRIE ADINA GOLDBERG PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	071.009961	IL
2	103TC0700X	Clinical Psychologist	071.009961	IL

General Provider Information

NPI Number	:	1821553934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORRIE ADINA GOLDBERG PH.D.

Provider Business Mailing Address
First Line	:	1006 MARION AVE
Second Line	:
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-5130
Country	:	US
Telephone Number	:	847-558-1546
Fax Number	:

Provider Business Practice Location Address
First Line	:	1189 WILMETTE AVE # 174
Second Line	:
City	:	WILMETTE
State	:	IL
Zip	:	60091-2719
Country	:	US
Telephone Number	:	847-558-1546
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2019
Last Update Date	:	02/07/2022

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