Provider Demographics
NPI:1154464030
Name:GOLDKLANK, SHELLY ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:ELLEN
Last Name:GOLDKLANK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 WEST END AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6248
Mailing Address - Country:US
Mailing Address - Phone:212-666-7004
Mailing Address - Fax:
Practice Address - Street 1:740 WEST END AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6248
Practice Address - Country:US
Practice Address - Phone:212-666-7004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7275103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVMS811Medicare ID - Type Unspecified