Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | PY00001795 | WA |
N | 103TC0700X | Clinical Psychologist | PY00001795 | WA |
Y | 103TR0400X | Rehabilitation Psychologist | PY00001795 | WA |
NPI | 1639254469 |
---|---|
Provider Name | Myron Lee Goldberg |
First Address | Seattle, WA 98145-5095 |
Second Address | Seattle, WA 98195-6157 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2006 |
Last Update Date | 10/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3516 | INTERNAL ID-MOTOR VEHICLE ID (01) | |
8352270 | (05) | WA |
P00088051 | RAIL ROAD MEDICARE (01) | WA |
R85625 | (02) |