Provider Demographics
NPI:1104866094
Name:GOLDMAN, VICTOR JAMES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:JAMES
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 HALLOCK AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1214
Mailing Address - Country:US
Mailing Address - Phone:631-928-4114
Mailing Address - Fax:631-476-0766
Practice Address - Street 1:1050 HALLOCK AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1214
Practice Address - Country:US
Practice Address - Phone:631-928-4114
Practice Address - Fax:631-476-0766
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLCSWR0119811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN09661Medicare ID - Type Unspecified