Provider Demographics
NPI:1033280623
Name:GOTTLIEB, CHARLES DAVID (MSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DAVID
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1620
Mailing Address - Country:US
Mailing Address - Phone:802-863-2325
Mailing Address - Fax:
Practice Address - Street 1:149 CHERRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3817
Practice Address - Country:US
Practice Address - Phone:802-863-2495
Practice Address - Fax:802-865-0534
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00000301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006770Medicaid
VT1006770Medicaid