Provider Demographics
NPI:1629330667
Name:GOLDSTEIN, MITZI D (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MITZI
Middle Name:D
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MITZI
Other - Middle Name:DANIELLE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3967
Mailing Address - Country:US
Mailing Address - Phone:843-761-8282
Mailing Address - Fax:843-761-7308
Practice Address - Street 1:403 STONEY LANDING RD.
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3967
Practice Address - Country:US
Practice Address - Phone:843-761-8282
Practice Address - Fax:843-761-7308
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC5771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMA COUNSELOROtherBH SOCIAL SERVICE