Provider Demographics
NPI:1114465846
Name:GOLDMAN, JUSTIN (MFT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 E 1ST ST # 264
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3211
Mailing Address - Country:US
Mailing Address - Phone:340-420-1623
Mailing Address - Fax:714-708-2588
Practice Address - Street 1:27173 LA CADENA DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:310-420-1623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93758106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist