Provider Demographics
NPI:1154424471
Name:GOLDSTEIN, MARK LLOYD (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LLOYD
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1893 SHERIDAN RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035
Mailing Address - Country:US
Mailing Address - Phone:847-926-0390
Mailing Address - Fax:847-498-8922
Practice Address - Street 1:1893 SHERIDAN RD
Practice Address - Street 2:SUITE 215
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035
Practice Address - Country:US
Practice Address - Phone:847-926-0390
Practice Address - Fax:847-498-8922
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL712066103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic