Provider Demographics
NPI:1154445252
Name:GOLDSTEIN, ELLYN LAURA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELLYN
Middle Name:LAURA
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 CONCORD RD SE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-5306
Mailing Address - Country:US
Mailing Address - Phone:770-434-1878
Mailing Address - Fax:770-434-5009
Practice Address - Street 1:1260 CONCORD RD SE
Practice Address - Street 2:SUITE 102
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-5306
Practice Address - Country:US
Practice Address - Phone:770-434-1878
Practice Address - Fax:770-434-5009
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA. LCSW 0930101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBFBSMedicare PIN