Provider Demographics
NPI:1366826083
Name:GOLDFADEN, MICHAEL S (MS,CAC-AD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:GOLDFADEN
Suffix:
Gender:M
Credentials:MS,CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 GREENBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-4424
Mailing Address - Country:US
Mailing Address - Phone:410-269-5605
Mailing Address - Fax:410-268-6965
Practice Address - Street 1:2610 GREENBRIAR LN
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-4424
Practice Address - Country:US
Practice Address - Phone:410-269-5605
Practice Address - Fax:410-268-6965
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0574101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)