Provider Demographics
NPI:1598090144
Name:GOLDMAN, REGINA LEE
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:LEE
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W KINZIE ST
Mailing Address - Street 2:2007
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 W KINZIE ST
Practice Address - Street 2:2007
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-5727
Practice Address - Country:US
Practice Address - Phone:847-951-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILG435-7328-7728103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst