Provider Demographics
NPI:1760786065
Name:GOLDSTEIN, FRED (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 OSTEMO PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1025
Mailing Address - Country:US
Mailing Address - Phone:574-292-5513
Mailing Address - Fax:
Practice Address - Street 1:1415 LINCOLNWAY W
Practice Address - Street 2:SUITE M
Practice Address - City:OSCEOLA
Practice Address - State:IN
Practice Address - Zip Code:46561-2062
Practice Address - Country:US
Practice Address - Phone:574-675-7767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22001315A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist