Provider Demographics
NPI:1902921836
Name:GOLDSTEIN, SUE-RITA (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SUE-RITA
Middle Name:
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2922
Mailing Address - Country:US
Mailing Address - Phone:401-861-1456
Mailing Address - Fax:
Practice Address - Street 1:105 MEDWAY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4401
Practice Address - Country:US
Practice Address - Phone:401-421-2604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW013931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI26430-7OtherBLUE CROSS