MEDICARE: JASON M GOLDBERG, LCSW-C, LLC

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	:	1871897959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JASON M GOLDBERG, LCSW-C, LLC

Provider Business Mailing Address
First Line	:	4815 SAINT ELMO AVE
Second Line	:	SUITE 100
City	:	BETHESDA
State	:	MD
Zip	:	20814-7061
Country	:	US
Telephone Number	:	301-664-6449
Fax Number	:	301-664-7922

Provider Business Practice Location Address
First Line	:	4815 SAINT ELMO AVE
Second Line	:	SUITE 100
City	:	BETHESDA
State	:	MD
Zip	:	20814-7061
Country	:	US
Telephone Number	:	301-664-6449
Fax Number	:	301-664-7922

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

Provider Enumeration Date	:	01/04/2011
Last Update Date	:	05/09/2011

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