Healthcare Provider Details

I. General information

NPI: 1184145047
Provider Name (Legal Business Name): GOLDBERG CONSULTING GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BASELINE ROAD SUITE C-1
TEMPE AZ
85283-1247
US

IV. Provider business mailing address

600 EAST BASELINE ROAD SUITE C-1
TEMPE AZ
85283-1267
US

V. Phone/Fax

Practice location:
  • Phone: 480-831-0746
  • Fax: 480-777-8521
Mailing address:
  • Phone: 480-831-0746
  • Fax: 480-777-8521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1045
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1045
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number1045
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1045
License Number StateAZ

VIII. Authorized Official

Name: DR. KENNETH J. GOLDBERG
Title or Position: 100 OWNER/PRESIDENT
Credential: ED.D.
Phone: 480-831-0746