Provider Demographics
NPI:1356955397
Name:GOLDSTEIN, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:124 CAPULET DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-4537
Practice Address - Country:US
Practice Address - Phone:904-429-7806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYK90367026OtherEMPIRE BLUE CROSS
NYK9036702604OtherEMBLEMHEALTH