1417106675 NPI number — DR. MATTHEW ETHAN GOLDENBERG PSY D

Table of content: DR. MATTHEW ETHAN GOLDENBERG PSY D (NPI 1417106675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417106675 NPI number — DR. MATTHEW ETHAN GOLDENBERG PSY D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDENBERG
Provider First Name:
MATTHEW
Provider Middle Name:
ETHAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417106675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 TUMWATER BLVD SE
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
TUMWATER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-395-9193
Provider Business Mailing Address Fax Number:
360-464-2720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 TUMWATER BLVD SE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
TUMWATER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-395-9193
Provider Business Practice Location Address Fax Number:
360-464-2720
Provider Enumeration Date:
09/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LH6039598 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: PY60416098 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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