Provider Demographics
NPI:1326164104
Name:GOLDMAN, GARY C (LMT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:C
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3839 VISTA CAMPANA S UNIT 17
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-8141
Mailing Address - Country:US
Mailing Address - Phone:760-722-3365
Mailing Address - Fax:
Practice Address - Street 1:336 ENCINITAS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-8707
Practice Address - Country:US
Practice Address - Phone:760-722-3365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25510106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist