Provider Demographics
NPI:1255477527
Name:GOLDSTEIN, MICHELLE WASSERMAN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:WASSERMAN
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:ELLEN
Other - Last Name:WASSERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:2650 OLIVE STREET
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1489
Mailing Address - Country:US
Mailing Address - Phone:314-371-6500
Mailing Address - Fax:314-371-1155
Practice Address - Street 1:12755 OLIVE BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-898-0100
Practice Address - Fax:314-439-5459
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0024761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical