Basic Information
| Provider Information | |||||||||
| NPI: | 1700937133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDMAN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32-34 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121671145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6076522000 | ||||||||
| FaxNumber: | 6076522433 | ||||||||
| Practice Location | |||||||||
| Address1: | 32-34 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121671145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6076522000 | ||||||||
| FaxNumber: | 6076522433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 4594 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 580869 | 05 | NY | MEDICAID |