MEDICARE: KRISTIN INGRID GOLDSTEIN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker		IL

General Provider Information

NPI Number	:	1295958064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN INGRID GOLDSTEIN LCSW

Provider Business Mailing Address
First Line	:	1157 W SCHUBERT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1308
Country	:	US
Telephone Number	:	773-832-1721
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 N WABASH AVE
Second Line	:	SUITE 3805
City	:	CHICAGO
State	:	IL
Zip	:	60611-3591
Country	:	US
Telephone Number	:	773-307-3361
Fax Number	:	312-222-1771

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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