Provider Demographics
NPI:1407866213
Name:GOLDSTEIN, MARY A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:A
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1005
Mailing Address - Country:US
Mailing Address - Phone:541-962-0162
Mailing Address - Fax:541-962-0119
Practice Address - Street 1:1501 6TH ST STE C
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2419
Practice Address - Country:US
Practice Address - Phone:541-963-6715
Practice Address - Fax:541-962-7440
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL28741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
118118Medicare ID - Type Unspecified