Provider Demographics
NPI:1518274182
Name:GOLDSMITH, TINA R (PHD, BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:R
Last Name:GOLDSMITH
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 TRINITY DR STE D-3
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2226
Mailing Address - Country:US
Mailing Address - Phone:505-412-4044
Mailing Address - Fax:
Practice Address - Street 1:3250 TRINITY DR STE D-3
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2226
Practice Address - Country:US
Practice Address - Phone:505-412-4044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1155103TC0700X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst