Provider Demographics
NPI:1427150879
Name:GOLDMAN, MARCIE ILENE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARCIE
Middle Name:ILENE
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1332 BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102
Mailing Address - Country:US
Mailing Address - Phone:619-952-8077
Mailing Address - Fax:619-239-7335
Practice Address - Street 1:4452 PARK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-4039
Practice Address - Country:US
Practice Address - Phone:619-952-8077
Practice Address - Fax:619-239-7335
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14404103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist