Provider Demographics
NPI:1396797213
Name:GOLDSTEIN, MARTIN ALLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ALLEN
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 1:8047 KEDVALE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-3227
Mailing Address - Country:US
Mailing Address - Phone:847-673-5733
Mailing Address - Fax:
Practice Address - Street 1:9239 GROSS POINT RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1389
Practice Address - Country:US
Practice Address - Phone:847-786-1500
Practice Address - Fax:847-677-5892
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TA0700X, 103TB0200X, 103TC0700X, 103TC2200X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL619110Medicare ID - Type UnspecifiedLAKE/DUPAGE CO.
IL956492Medicare ID - Type UnspecifiedCOOK CO.