Basic Information
| Provider Information | |||||||||
| NPI: | 1033557053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | ADLER | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W. | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 16974 | MD | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 0904008471 | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 15485 | 05 | MD | MEDICAID |