Provider Demographics
NPI: | 1407297377 |
---|---|
Name: | GOITEIN, ALEXANDER (LCSW, PPSC, BCBA) |
Entity Type: | Individual |
Prefix: | |
First Name: | ALEXANDER |
Middle Name: | |
Last Name: | GOITEIN |
Suffix: | |
Gender: | M |
Credentials: | LCSW, PPSC, BCBA |
Other - Prefix: | |
Other - First Name: | ALEX |
Other - Middle Name: | |
Other - Last Name: | GOITEIN |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | |
Mailing Address - Street 1: | 3808 ZIEBER RD |
Mailing Address - Street 2: | |
Mailing Address - City: | SANTA ROSA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95404-2636 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 707-575-3290 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1028 PRINCE AVE |
Practice Address - Street 2: | |
Practice Address - City: | HEALDSBURG |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95448-3596 |
Practice Address - Country: | US |
Practice Address - Phone: | 707-431-3488 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2013-07-08 |
Last Update Date: | 2023-06-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 1-14-17837 | 103K00000X |
CA | 82400 | 1041C0700X |
CA | PPSC-200145814 | 1041S0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041S0200X | Behavioral Health & Social Service Providers | Social Worker | School |
No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |