Basic Information
Provider Information
NPI: 1033557053
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GOLDBERG
FirstName: REBECCA
MiddleName: ADLER
NamePrefix: MS.
NameSuffix:  
Credential: M.S.W.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1483 CHAIN BRIDGE RD
Address2: SUITE 301
City: MC LEAN
State: VA
PostalCode: 221015703
CountryCode: US
TelephoneNumber: 2409941653
FaxNumber:  
Practice Location
Address1: 1483 CHAIN BRIDGE RD
Address2: SUITE 301
City: MC LEAN
State: VA
PostalCode: 221015703
CountryCode: US
TelephoneNumber: 2409941653
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/12/2013
LastUpdateDate: 01/23/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000X16974MDN Behavioral Health & Social Service ProvidersSocial Worker 
1041C0700X0904008471VAY Behavioral Health & Social Service ProvidersSocial WorkerClinical

ID Information
IDTypeStateIssuerDescription
1548505MD MEDICAID


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