Healthcare Provider Details

I. General information

NPI: 1407532708
Provider Name (Legal Business Name): KELLY GOLDBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/24/2023
Certification Date: 06/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8767 CARMEL VALLEY RD
CARMEL CA
93923-7958
US

IV. Provider business mailing address

8767 CARMEL VALLEY RD
CARMEL CA
93923-7958
US

V. Phone/Fax

Practice location:
  • Phone: 831-293-4492
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: