Provider Demographics
NPI:1861720971
Name:GOLDBLATT, NATHANIEL (PSYD)
Entity type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:
Last Name:GOLDBLATT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 W RACE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-6248
Mailing Address - Country:US
Mailing Address - Phone:773-880-2400
Mailing Address - Fax:773-880-2402
Practice Address - Street 1:2835 N SHEFFIELD AVE STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5083
Practice Address - Country:US
Practice Address - Phone:312-863-9549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007696103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist