Provider Demographics
NPI:1710350442
Name:GOLDMAN, RYAN (LPC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16017 S 45TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11301 N 99TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-5466
Practice Address - Country:US
Practice Address - Phone:623-977-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LPC 15898101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional