Provider Demographics
NPI:1801821954
Name:GOLDENTHAL, MARK HOWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:HOWARD
Last Name:GOLDENTHAL
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 1:127 W 79TH ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-6416
Mailing Address - Country:US
Mailing Address - Phone:212-799-1303
Mailing Address - Fax:
Practice Address - Street 1:127 W 79TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6416
Practice Address - Country:US
Practice Address - Phone:212-799-1303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2759103TF0000X, 103TP0814X, 103T00000X
NY08919103TF0000X, 103TP0814X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist