Provider Demographics
NPI:1255865218
Name:GOLDSTEIN, CARLY MICHELLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARLY
Middle Name:MICHELLE
Last Name:GOLDSTEIN
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 1:196 RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4212
Mailing Address - Country:US
Mailing Address - Phone:401-793-8960
Mailing Address - Fax:401-793-8943
Practice Address - Street 1:196 RICHMOND ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4212
Practice Address - Country:US
Practice Address - Phone:401-793-8960
Practice Address - Fax:401-793-8943
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01614103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical