Provider Demographics
NPI:1306698550
Name:GOLDSTEIN, KYLE ELY (CDN)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ELY
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CREAMERY RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-1973
Mailing Address - Country:US
Mailing Address - Phone:914-799-2023
Mailing Address - Fax:
Practice Address - Street 1:204 MEADOW RIDGE ACRES RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337-7805
Practice Address - Country:US
Practice Address - Phone:914-799-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012026133NN1002X, 171400000X, 174H00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No171400000XOther Service ProvidersHealth & Wellness Coach
No174H00000XOther Service ProvidersHealth Educator