MEDICARE: MICHAEL A GOLDMAN LCSW, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	242	WV
2	104100000X	Social Worker	CP00452118	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001721391	OTHER	WV	MOUNTAIN STATE BC/BS

General Provider Information

NPI Number	:	1326009523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL A GOLDMAN LCSW, LPC

Provider Business Mailing Address
First Line	:	2585 3RD AVE
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25703-1642
Country	:	US
Telephone Number	:	304-781-5159
Fax Number	:	304-523-8115

Provider Business Practice Location Address
First Line	:	203 KENOVA AVE
Second Line	:
City	:	WAYNE
State	:	WV
Zip	:	25570-9795
Country	:	US
Telephone Number	:	304-272-5136
Fax Number	:	304-272-3807

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	03/14/2016

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