Healthcare Provider Details

I. General information

NPI: 1861571416
Provider Name (Legal Business Name): KENNETH STEPHEN GOLDSTEIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 SE BROWNING RD
EVANSVILLE IN
47725-9046
US

IV. Provider business mailing address

2301 SE BROWNING RD
EVANSVILLE IN
47725-9046
US

V. Phone/Fax

Practice location:
  • Phone: 812-433-3333
  • Fax:
Mailing address:
  • Phone: 812-433-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20010164A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: