Provider Demographics
NPI:1326009523
Name:GOLDMAN, MICHAEL A (LCSW, LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:LCSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-781-5159
Mailing Address - Fax:304-523-8115
Practice Address - Street 1:203 KENOVA AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:WV
Practice Address - Zip Code:25570-9795
Practice Address - Country:US
Practice Address - Phone:304-272-5136
Practice Address - Fax:304-272-3807
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV242101YP2500X
WVCP00452118104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001721391OtherMOUNTAIN STATE BC/BS