Provider Demographics
NPI:1114033263
Name:GOLDSTEIN, GARY MARSHALL (LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MARSHALL
Last Name:GOLDSTEIN
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 1:565 TURNPIKE STREET
Mailing Address - Street 2:SUITE 81
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845
Mailing Address - Country:US
Mailing Address - Phone:918-682-1579
Mailing Address - Fax:978-689-4582
Practice Address - Street 1:565 TURNPIKE STREET
Practice Address - Street 2:SUITE 81
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845
Practice Address - Country:US
Practice Address - Phone:918-682-1579
Practice Address - Fax:978-689-4582
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA102691103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01307Medicare ID - Type Unspecified