=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861721243
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASON M. GOLDBERG, LCSW-C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2009
-----------------------------------------------------
Last Update Date | 12/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 E WEST HWY SUITE 207
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814-4523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-329-7696
-----------------------------------------------------
Fax | 301-907-3342
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4401 E WEST HWY SUITE 207
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814-4523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-329-7696
-----------------------------------------------------
Fax | 301-907-3342
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OF PSYCHOTHERAPY PRACTICE
-----------------------------------------------------
Name | MR. JASON MATTHEW GOLDBERG
-----------------------------------------------------
Credential | LCSW-C
-----------------------------------------------------
Telephone | 202-329-7696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 12697
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------