Provider Demographics
NPI:1720399462
Name:GOLDSTEIN, SUSAN SHAYNE
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:SHAYNE
Last Name:GOLDSTEIN
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 1:11125 SCHUETZ RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4909
Mailing Address - Country:US
Mailing Address - Phone:314-853-3914
Mailing Address - Fax:314-692-8113
Practice Address - Street 1:11125 SCHUETZ RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4909
Practice Address - Country:US
Practice Address - Phone:314-853-3914
Practice Address - Fax:314-692-8113
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004019225225X00000X, 225XE0001X, 225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology