Provider Demographics
NPI:1215121710
Name:GOLDSTEIN, CLARK R (PHD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:R
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 1:1981 MARCUS AVENUE
Mailing Address - Street 2:SUITE C-102 NYU CHILD STUDY CENTER
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-358-1808
Mailing Address - Fax:646-754-9854
Practice Address - Street 1:1981 MARCUS AVENUE
Practice Address - Street 2:SUITE C-102 NYU CHILD STUDY CENTER
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-358-1808
Practice Address - Fax:646-754-9854
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY019503103T00000X
NY50019503103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18708OtherBLUE CROSS
MA1312677Medicaid
MAM20807Medicare PIN