Healthcare Provider Details

I. General information

NPI: 1982125514
Provider Name (Legal Business Name): STEFAN GOLDBERG MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 07/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 NE KILLINGSWORTH ST
PORTLAND OR
97218-1404
US

IV. Provider business mailing address

2937 NE 33RD AVE
PORTLAND OR
97212-3653
US

V. Phone/Fax

Practice location:
  • Phone: 503-535-1181
  • Fax:
Mailing address:
  • Phone: 510-499-4503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: