Provider Demographics
NPI:1265908636
Name:GOLDMAN, LAUREL BETH
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:BETH
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4447 N KEDZIE AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-6636
Mailing Address - Country:US
Mailing Address - Phone:312-206-6280
Mailing Address - Fax:
Practice Address - Street 1:4314 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3514
Practice Address - Country:US
Practice Address - Phone:312-747-0036
Practice Address - Fax:312-747-2208
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1265758619Medicaid