MEDICARE: JEREMY JOSEPH-LI GOLDBERG LCSW

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	1041C0700X	Clinical Social Worker	9285	FL

General Provider Information

NPI Number	:	1710119524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY JOSEPH-LI GOLDBERG LCSW

Provider Business Mailing Address
First Line	:	925 S SEMORAN BLVD
Second Line	:	SUITE 114
City	:	WINTER PARK
State	:	FL
Zip	:	32792-5313
Country	:	US
Telephone Number	:	407-621-2630
Fax Number	:	407-621-2671

Provider Business Practice Location Address
First Line	:	925 S SEMORAN BLVD
Second Line	:	SUITE 114
City	:	WINTER PARK
State	:	FL
Zip	:	32792-5313
Country	:	US
Telephone Number	:	407-621-2630
Fax Number	:	407-621-2671

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

Provider Enumeration Date	:	08/12/2009
Last Update Date	:	08/12/2009

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