Provider Demographics
NPI:1790745248
Name:GOLDSTEIN, SAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 S 500 E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2015
Mailing Address - Country:US
Mailing Address - Phone:801-532-1484
Mailing Address - Fax:801-532-1486
Practice Address - Street 1:230 S 500 E
Practice Address - Street 2:SUITE 100
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84102-2015
Practice Address - Country:US
Practice Address - Phone:801-532-1484
Practice Address - Fax:801-532-1486
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT110924-2501103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R56069Medicare UPIN
UT0000002477Medicare ID - Type Unspecified