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General NPI Number Information
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NPI Number | 1043340987
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Entity Type | Individual
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Provider Name | MICHAEL W GOLDBERG M.A.
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Gender | Male
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 113 HAWK DRIVE
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City | DULCE
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State | NM
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Zip | 87528
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Country | US
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Telephone | 505-759-2954
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Fax | 505-759-1349
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Provider Business Mailing Address
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Address Line | 98 BULL ELK PL
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City | PAGOSA SPRINGS
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State | CO
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Zip | 81147-8511
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 308194
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License Number State | NM
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