Provider Demographics
NPI:1104100965
Name:GOLDWERT, ILAINA (PHD)
Entity type:Individual
Prefix:
First Name:ILAINA
Middle Name:
Last Name:GOLDWERT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 UNION ST APT 2D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-1609
Mailing Address - Country:US
Mailing Address - Phone:973-464-9768
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY
Practice Address - Street 2:SUITE 800
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6008
Practice Address - Country:US
Practice Address - Phone:347-915-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020680103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical