Provider Demographics
NPI:1003140039
Name:KOTTHA, CARMEN K (LISW)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:K
Last Name:KOTTHA
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24800 CHAGRIN BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5648
Mailing Address - Country:US
Mailing Address - Phone:216-245-6231
Mailing Address - Fax:216-245-6351
Practice Address - Street 1:24800 CHAGRIN BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5648
Practice Address - Country:US
Practice Address - Phone:216-245-6231
Practice Address - Fax:216-245-6351
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0900019104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid