Provider Demographics
NPI:1144424334
Name:KOTLER, GWEN H (MSW,LCSW)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:H
Last Name:KOTLER
Suffix:
Gender:F
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BLACK PINE WAY
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-1863
Mailing Address - Country:US
Mailing Address - Phone:386-671-7738
Mailing Address - Fax:
Practice Address - Street 1:533 N NOVA RD
Practice Address - Street 2:SUITE 203
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-4447
Practice Address - Country:US
Practice Address - Phone:386-334-8430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 73981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW 7398OtherLICENSED SOCIAL WORKER