Healthcare Provider Details

I. General information

NPI: 1952542383
Provider Name (Legal Business Name): SULA GOLDENBERG LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2009
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1913 E 17TH ST
NORTH TUSTIN CA
92705-8627
US

IV. Provider business mailing address

PO BOX 8042
FOUNTAIN VALLEY CA
92728-8042
US

V. Phone/Fax

Practice location:
  • Phone: 714-376-7136
  • Fax: 714-543-6730
Mailing address:
  • Phone: 714-376-7136
  • Fax: 714-543-6730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 46487
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: