Provider Demographics
NPI:1497821912
Name:GOLDMAN, JEREMY MARC (NCC LCPC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:MARC
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:NCC LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 RIDGLAND ROAD
Mailing Address - Street 2:STE 1
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030
Mailing Address - Country:US
Mailing Address - Phone:410-628-6120
Mailing Address - Fax:410-628-9825
Practice Address - Street 1:10400 RIDGLAND ROAD
Practice Address - Street 2:STE 1
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030
Practice Address - Country:US
Practice Address - Phone:410-628-6120
Practice Address - Fax:410-628-9825
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2140101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional