Provider Demographics
NPI:1144782657
Name:GOTTLOB, ALECIA ANN (BA)
Entity Type:Individual
Prefix:
First Name:ALECIA
Middle Name:ANN
Last Name:GOTTLOB
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 882
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-0882
Mailing Address - Country:US
Mailing Address - Phone:907-283-3658
Mailing Address - Fax:907-283-5046
Practice Address - Street 1:10200 KENAI SPUR HWY
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7807
Practice Address - Country:US
Practice Address - Phone:907-283-3658
Practice Address - Fax:907-283-5046
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)