Provider Demographics
NPI:1386621910
Name:GOLDSTEIN, MARVIN (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 E 3900 S SUITE A 170
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:801-284-4990
Mailing Address - Fax:
Practice Address - Street 1:1141 E 3900 S
Practice Address - Street 2:A-170
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1215
Practice Address - Country:US
Practice Address - Phone:801-284-4990
Practice Address - Fax:801-284-4991
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13809135011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTNPP000Medicare UPIN