1255477527 NPI number — MRS. MICHELLE WASSERMAN GOLDSTEIN MSW

Table of content: MRS. MICHELLE WASSERMAN GOLDSTEIN MSW (NPI 1255477527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255477527 NPI number — MRS. MICHELLE WASSERMAN GOLDSTEIN MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDSTEIN
Provider First Name:
MICHELLE
Provider Middle Name:
WASSERMAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WASSERMAN
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255477527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 OLIVE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63103-1489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-371-6500
Provider Business Mailing Address Fax Number:
314-371-1155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12755 OLIVE BLVD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-898-0100
Provider Business Practice Location Address Fax Number:
314-439-5459
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  002476 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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