Provider Demographics
NPI:1841251204
Name:GOLDMAN, GARY (PSYD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MILL ST
Mailing Address - Street 2:SUITE 004
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-4784
Mailing Address - Country:US
Mailing Address - Phone:781-646-0500
Mailing Address - Fax:781-646-7130
Practice Address - Street 1:22 MILL ST
Practice Address - Street 2:SUITE 004
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4784
Practice Address - Country:US
Practice Address - Phone:781-646-0500
Practice Address - Fax:781-646-7130
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6514103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50083Medicare UPIN