Healthcare Provider Details

I. General information

NPI: 1740708155
Provider Name (Legal Business Name): LEORA GOLDENBERG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98120 QUEENS BLVD STE 1C
REGO PARK NY
11374-4414
US

IV. Provider business mailing address

1428 BEACON PL
FAR ROCKAWAY NY
11691-1608
US

V. Phone/Fax

Practice location:
  • Phone: 718-830-0246
  • Fax:
Mailing address:
  • Phone: 347-631-3339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number096536
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number095770
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: