Provider Demographics
NPI:1164759551
Name:GOTTLIEB, RICHARD JASON (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JASON
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 NW 78TH DR
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33067-2466
Mailing Address - Country:US
Mailing Address - Phone:954-340-9537
Mailing Address - Fax:
Practice Address - Street 1:6400 NW 78TH DR
Practice Address - Street 2:
Practice Address - City:PARKLAND
Practice Address - State:FL
Practice Address - Zip Code:33067-2466
Practice Address - Country:US
Practice Address - Phone:954-340-9537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8082225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist