Provider Demographics
NPI:1376606863
Name:GOLDSTEIN, MARK JOEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOEL
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 LAS GALLINAS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3434
Mailing Address - Country:US
Mailing Address - Phone:415-444-3522
Mailing Address - Fax:
Practice Address - Street 1:820 LAS GALLINAS AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3410
Practice Address - Country:US
Practice Address - Phone:415-444-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6680103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist