Provider Demographics
NPI:1366902488
Name:GOLDBERG, CHARLES ROSS (LPC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ROSS
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 CHEROKEE ST APT 104
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-2623
Mailing Address - Country:US
Mailing Address - Phone:224-430-3659
Mailing Address - Fax:
Practice Address - Street 1:940 CHEROKEE ST APT 104
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-2623
Practice Address - Country:US
Practice Address - Phone:224-430-3659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-24
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011147101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty