Provider Demographics
NPI:1437200680
Name:GOLDBERG, KENNETH B (PSYD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CATHLEEN DR
Mailing Address - Street 2:
Mailing Address - City:RICHBORO
Mailing Address - State:PA
Mailing Address - Zip Code:18954-1451
Mailing Address - Country:US
Mailing Address - Phone:215-968-9380
Mailing Address - Fax:215-968-9385
Practice Address - Street 1:1650 HUNTINGDON PIKE
Practice Address - Street 2:
Practice Address - City:MEADOWBROOK
Practice Address - State:PA
Practice Address - Zip Code:19046-8004
Practice Address - Country:US
Practice Address - Phone:215-968-9380
Practice Address - Fax:215-968-9385
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008680L103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS45856Medicare UPIN
PA002689RCDMedicare PIN
PA0620005890Medicare NSC