Provider Demographics
NPI:1093712333
Name:GOTTLICH, JAMES H (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:H
Last Name:GOTTLICH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 MATTISON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2619
Mailing Address - Country:US
Mailing Address - Phone:817-732-8441
Mailing Address - Fax:817-732-1833
Practice Address - Street 1:3704 MATTISON AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2619
Practice Address - Country:US
Practice Address - Phone:817-732-8441
Practice Address - Fax:817-732-1833
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX166261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R6009Medicare UPIN
83412WMedicare ID - Type Unspecified