Provider Demographics
NPI:1962496463
Name:GOLDSTEIN, STANLEY M (PHD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:M
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 1:1050 ROUTE 211 EAST
Mailing Address - Street 2:P.O. BOX 4732
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-8732
Mailing Address - Country:US
Mailing Address - Phone:845-692-0614
Mailing Address - Fax:815-642-9611
Practice Address - Street 1:1050 ROUTE 211 E
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-3726
Practice Address - Country:US
Practice Address - Phone:845-692-0614
Practice Address - Fax:815-642-9611
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2010-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004697-1103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV17851Medicare ID - Type Unspecified