Healthcare Provider Details

I. General information

NPI: 1407869704
Provider Name (Legal Business Name): MARJORIE PROVOST GOLDBAUM LICSW LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CHELMSFORD ST
CHELMSFORD MA
01824-2359
US

IV. Provider business mailing address

201 CHELMSFORD ST
CHELMSFORD MA
01824-2359
US

V. Phone/Fax

Practice location:
  • Phone: 978-256-1467
  • Fax: 978-256-7465
Mailing address:
  • Phone: 978-256-1467
  • Fax: 978-256-7465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110711
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1530
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: