Healthcare Provider Details

I. General information

NPI: 1366485807
Provider Name (Legal Business Name): MICHAEL A. GOLDSTEIN PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PETTIS MEMORIAL VAMC, 11201 BENTON STREET
LOMA LINDA CA
92357-0001
US

IV. Provider business mailing address

PETTIS MEMORIAL VAMC, 11201 BENTON STREET
LOMA LINDA CA
92357-0001
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 909-825-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY9408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: