Provider Demographics
NPI:1104113083
Name:GOLDMAN, STEPHANIE DIANE (BHR)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:DIANE
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:BHR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E PROCTOR AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-4239
Mailing Address - Country:US
Mailing Address - Phone:580-819-3200
Mailing Address - Fax:
Practice Address - Street 1:403 N CLARENCE NASH BLVD
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-3636
Practice Address - Country:US
Practice Address - Phone:580-623-5433
Practice Address - Fax:580-623-2409
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation