Healthcare Provider Details

I. General information

NPI: 1376237917
Provider Name (Legal Business Name): MARK DAVID GOLDENBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD, BLDG 217, RM 226
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

6230 WILSHIRE BLVD STE A
LOS ANGELES CA
90048-5126
US

V. Phone/Fax

Practice location:
  • Phone: 310-435-4068
  • Fax:
Mailing address:
  • Phone: 310-435-4068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW85274
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number129408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: