Provider Demographics
NPI:1679554463
Name:GOLDBERG, ATHENA WIND
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:WIND
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ATHENA
Other - Middle Name:WIND
Other - Last Name:GOLDBERG-JOHNS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2180 MILFORD DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-4348
Mailing Address - Country:US
Mailing Address - Phone:541-772-3993
Mailing Address - Fax:
Practice Address - Street 1:18 MYRTLE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7471
Practice Address - Country:US
Practice Address - Phone:541-245-5577
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL35761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130560Medicare ID - Type Unspecified