Healthcare Provider Details

I. General information

NPI: 1114465846
Provider Name (Legal Business Name): JUSTIN GOLDMAN MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 04/12/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27173 LA CADENA DR
LAGUNA HILLS CA
92653
US

IV. Provider business mailing address

360 E 1ST ST # 264
TUSTIN CA
92780-3211
US

V. Phone/Fax

Practice location:
  • Phone: 310-420-1623
  • Fax:
Mailing address:
  • Phone: 340-420-1623
  • Fax: 714-708-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number93758
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: