Provider Demographics
NPI:1063532935
Name:GOLDSTEIN, ELLYN S (MS)
Entity type:Individual
Prefix:MS
First Name:ELLYN
Middle Name:S
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 E THOUSAND OAKS BLVD
Mailing Address - Street 2:SUITE #116
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-2827
Mailing Address - Country:US
Mailing Address - Phone:805-630-0242
Mailing Address - Fax:
Practice Address - Street 1:1337 E THOUSAND OAKS BLVD
Practice Address - Street 2:SUITE #116
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-2827
Practice Address - Country:US
Practice Address - Phone:805-630-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC43205106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist