Provider Demographics
NPI:1447369459
Name:GOLDSTEIN, LEONARD I (PSYD)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:I
Last Name:GOLDSTEIN
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 1:133 SCOVILL ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1127
Mailing Address - Country:US
Mailing Address - Phone:203-573-9521
Mailing Address - Fax:203-573-8708
Practice Address - Street 1:133 SCOVILL ST
Practice Address - Street 2:SUITE 211
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1127
Practice Address - Country:US
Practice Address - Phone:203-573-9521
Practice Address - Fax:203-573-8708
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001856103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004132007Medicaid
CT060001856CT01OtherBLUE SHIELD
CT004132007Medicaid