Provider Demographics
NPI:1598425639
Name:GOLDSTEIN, ELIANA MIRIAM
Entity Type:Individual
Prefix:
First Name:ELIANA
Middle Name:MIRIAM
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIANA
Other - Middle Name:MIRIAM
Other - Last Name:LANDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCBA
Mailing Address - Street 1:34 KLETSK HILL RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-2971
Mailing Address - Country:US
Mailing Address - Phone:773-592-2328
Mailing Address - Fax:
Practice Address - Street 1:1776 AVENUE OF THE STATES
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4591
Practice Address - Country:US
Practice Address - Phone:800-604-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ12155253103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst