Provider Demographics
NPI:1346413515
Name:GOLDMAN, ALEX B (MA, LPC, CSAC)
Entity Type:Individual
Prefix:MR
First Name:ALEX
Middle Name:B
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:MA, LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11414 W PARK PLACE SUITE 202
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224
Mailing Address - Country:US
Mailing Address - Phone:414-292-7060
Mailing Address - Fax:888-965-2080
Practice Address - Street 1:11414 W PARK PLACE SUITE 202
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224
Practice Address - Country:US
Practice Address - Phone:414-292-7060
Practice Address - Fax:414-871-9121
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14468-132101YA0400X
WI4808-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39175300Medicaid