| Doctor Name: | GLENN MARSHALL GOLDBERG |
| NPI Number: | 1093798936 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PHD |
| License Number: | 0810002028 |
| Business Practice Address: | 9 St. Johns Medical Park Drive St. Augustine, FL - 32086 |
| Business Phone Number: | 9047972705 |
| Business Fax Number: | 9047972820 |
| Mailing Address: | 9 St. Johns Medical Park Drive, ST. AUGUSTINE |
| State: | FL |
| Postal Code: | 32086 |
| Phone Number: | 9047972705 |
| Fax Number: | 9047972820 |
| NPI Enumeration Date: | 11/23/2005 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 0810002028 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | VA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |