MEDICARE: KEITH GOLIN PH.D.

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	103TC0700X	Clinical Psychologist	35SI0040990	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1487660213	OTHER	NJ	PRIMARY INSURANCE CO

General Provider Information

NPI Number	:	1689610875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH GOLIN PH.D.

Provider Business Mailing Address
First Line	:	18 ASPEN DR
Second Line	:
City	:	LIVINGSTON
State	:	NJ
Zip	:	07039-1432
Country	:	US
Telephone Number	:	888-284-2034
Fax Number	:	973-992-4639

Provider Business Practice Location Address
First Line	:	659 EAGLE ROCK AVE
Second Line	:	STE 4
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-2138
Country	:	US
Telephone Number	:	888-284-2034
Fax Number	:	973-992-4639

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

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	05/24/2021

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Directions to “ KEITH GOLIN PH.D.” Practice Location

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