Provider Demographics
NPI:1073553905
Name:GOTTSHALL, CONSTANCE C (MSRD)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:C
Last Name:GOTTSHALL
Suffix:
Gender:F
Credentials:MSRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-2414
Mailing Address - Country:US
Mailing Address - Phone:304-536-4870
Mailing Address - Fax:304-536-1664
Practice Address - Street 1:320 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE SULPHUR SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:24986-2414
Practice Address - Country:US
Practice Address - Phone:304-536-4870
Practice Address - Fax:304-536-1664
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV711242133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVMT04271Medicare PIN