Provider Demographics
NPI:1043881063
Name:GOTTLIEB, BRYAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 5TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-709-6529
Practice Address - Street 1:964 ISABEL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7482
Practice Address - Country:US
Practice Address - Phone:717-274-9777
Practice Address - Fax:717-274-9815
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019290103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
15372983OtherCAQH
PAPS019290OtherSTATE LICENSE
PA103933713Medicaid