Provider Demographics
NPI:1578885513
Name:MARCIE I. GOLDMAN, PH.D, PSYCHOLOGIST, INC.
Entity Type:Organization
Organization Name:MARCIE I. GOLDMAN, PH.D, PSYCHOLOGIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCIE
Authorized Official - Middle Name:ILENE
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:619-952-8077
Mailing Address - Street 1:1332 BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2430
Mailing Address - Country:US
Mailing Address - Phone:619-952-8077
Mailing Address - Fax:619-239-7335
Practice Address - Street 1:4452 PARK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-4039
Practice Address - Country:US
Practice Address - Phone:619-952-8077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14404103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty