Healthcare Provider Details

I. General information

NPI: 1265908636
Provider Name (Legal Business Name): LAUREL BETH GOLDMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4314 S COTTAGE GROVE AVE
CHICAGO IL
60653-3514
US

IV. Provider business mailing address

4447 N KEDZIE AVE APT 302
CHICAGO IL
60625-6636
US

V. Phone/Fax

Practice location:
  • Phone: 312-747-0036
  • Fax: 312-747-2208
Mailing address:
  • Phone: 312-206-6280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: