Basic Information
| Provider Information | |||||||||
| NPI: | 1629330667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDSTEIN | ||||||||
| FirstName: | MITZI | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | MITZI | ||||||||
| OtherMiddleName: | DANIELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1030 | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294613967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437618282 | ||||||||
| FaxNumber: | 8437617308 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 STONEY LANDING RD. | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294613967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437618282 | ||||||||
| FaxNumber: | 8437617308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2012 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 5771 | SC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MA COUNSELOR | 01 | MA | BH SOCIAL SERVICE | OTHER |