MEDICARE: JASON M. GOLDBERG, LCSW-C

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	12697	MD

General Provider Information

NPI Number	:	1861721243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JASON M. GOLDBERG, LCSW-C

Provider Business Mailing Address
First Line	:	4401 E WEST HWY
Second Line	:	SUITE 207
City	:	BETHESDA
State	:	MD
Zip	:	20814-4523
Country	:	US
Telephone Number	:	202-329-7696
Fax Number	:	301-907-3342

Provider Business Practice Location Address
First Line	:	4401 E WEST HWY
Second Line	:	SUITE 207
City	:	BETHESDA
State	:	MD
Zip	:	20814-4523
Country	:	US
Telephone Number	:	202-329-7696
Fax Number	:	301-907-3342

Authorized Official
Title or Position	:	OWNER OF PSYCHOTHERAPY PRACTICE
Name	:	MR. JASON MATTHEW GOLDBERG
Credential	:	LCSW-C
Telephone Number	:	202-329-7696

Provider Enumeration Date	:	12/15/2009
Last Update Date	:	12/15/2009

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