Provider Demographics
NPI:1609079821
Name:GOLDSTEIN, BONNIE MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:MARK
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:SOLOMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10825 ASHBY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064
Mailing Address - Country:US
Mailing Address - Phone:310-475-2323
Mailing Address - Fax:310-475-5323
Practice Address - Street 1:10825 ASHBY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064
Practice Address - Country:US
Practice Address - Phone:310-475-2323
Practice Address - Fax:310-475-5323
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15621103T00000X
CA128581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical