Basic Information
| Provider Information | |||||||||
| NPI: | 1982784427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLBERG-GOLDSTEIN | ||||||||
| FirstName: | EVA | ||||||||
| MiddleName: | HARRIETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-R | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KJELLBERG-GOLDSTEIN | ||||||||
| OtherFirstName: | EVA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW-R | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | FEGS 9745 QUEENS BOULVARD | ||||||||
| Address2: | PENTHOUSE FLOOR | ||||||||
| City: | REGO PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113742116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188969090 | ||||||||
| FaxNumber: | 7188300724 | ||||||||
| Practice Location | |||||||||
| Address1: | FEGS 9745 QUEENS BOULVARD | ||||||||
| Address2: | PENT HOUSE FLOOR | ||||||||
| City: | REGO PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113742116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188969090 | ||||||||
| FaxNumber: | 7188300724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 01/14/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | RO46277-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.