Provider Demographics
NPI:1669407532
Name:GOLDMAN, MICHAEL STUART (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STUART
Last Name:GOLDMAN
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 1:547 S VENANGO DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-7055
Mailing Address - Country:US
Mailing Address - Phone:719-281-5056
Mailing Address - Fax:719-960-2475
Practice Address - Street 1:547 S VENANGO DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-7055
Practice Address - Country:US
Practice Address - Phone:719-248-9343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2019-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2169103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07021694Medicaid
CO07021694Medicaid