Healthcare Provider Details

I. General information

NPI: 1497821912
Provider Name (Legal Business Name): JEREMY MARC GOLDMAN NCC LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 RIDGLAND ROAD STE 1
COCKEYSVILLE MD
21030
US

IV. Provider business mailing address

10400 RIDGLAND ROAD STE 1
COCKEYSVILLE MD
21030
US

V. Phone/Fax

Practice location:
  • Phone: 410-628-6120
  • Fax: 410-628-9825
Mailing address:
  • Phone: 410-628-6120
  • Fax: 410-628-9825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC2140
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: