Healthcare Provider Details

I. General information

NPI: 1407866213
Provider Name (Legal Business Name): MARY A GOLDSTEIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 6TH ST STE C
LA GRANDE OR
97850-2419
US

IV. Provider business mailing address

PO BOX 1005
LA GRANDE OR
97850-1005
US

V. Phone/Fax

Practice location:
  • Phone: 541-963-6715
  • Fax: 541-962-7440
Mailing address:
  • Phone: 541-962-0162
  • Fax: 541-962-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL2874
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: