Provider Demographics
NPI:1043631211
Name:GOTTLIEB, LEV (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEV
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MIDVALE AVE
Mailing Address - Street 2:404
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5498
Mailing Address - Country:US
Mailing Address - Phone:424-835-0854
Mailing Address - Fax:
Practice Address - Street 1:1400 MIDVALE AVE
Practice Address - Street 2:404
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5498
Practice Address - Country:US
Practice Address - Phone:424-835-0854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY 26509103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program