Provider Demographics
NPI:1053599282
Name:GOLDBERG, DIANA GRAY (LCSW)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:GRAY
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W 70TH ST
Mailing Address - Street 2:#3F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-3504
Mailing Address - Country:US
Mailing Address - Phone:212-579-1997
Mailing Address - Fax:
Practice Address - Street 1:315 W 70TH ST
Practice Address - Street 2:#3F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-3504
Practice Address - Country:US
Practice Address - Phone:212-579-1997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072784-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN362H1OtherMEDICARE PROVIDER #