Provider Demographics
NPI:1538478011
Name:GOLDMAN, IRIT (MFT)
Entity Type:Individual
Prefix:DR
First Name:IRIT
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 FORD AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4631
Mailing Address - Country:US
Mailing Address - Phone:209-605-9626
Mailing Address - Fax:209-577-3412
Practice Address - Street 1:1604 FORD AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4631
Practice Address - Country:US
Practice Address - Phone:209-605-9626
Practice Address - Fax:209-577-3412
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46437103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26-3608004OtherEIN