MEDICARE: MR. IRA JACK GOLDBERG MS MFT LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	290L	NV
2	106H00000X	Marriage & Family Therapist	0235	NV

General Provider Information

NPI Number	:	1457464919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IRA JACK GOLDBERG MS MFT LADC

Provider Business Mailing Address
First Line	:	3602 E SUNSET RD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-7230
Country	:	US
Telephone Number	:	702-932-4308
Fax Number	:	702-837-8930

Provider Business Practice Location Address
First Line	:	3602 E SUNSET RD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-7230
Country	:	US
Telephone Number	:	702-932-4308
Fax Number	:	702-837-8930

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	02/18/2011

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