Provider Demographics
NPI:1194827360
Name:LOTTES, ALICE ANNE (PHD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:ANNE
Last Name:LOTTES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 MARATHON BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3409
Mailing Address - Country:US
Mailing Address - Phone:512-451-3496
Mailing Address - Fax:512-451-3498
Practice Address - Street 1:4201 MARATHON BLVD STE 206
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3409
Practice Address - Country:US
Practice Address - Phone:512-451-3496
Practice Address - Fax:512-451-3498
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31930103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00417HMedicare ID - Type Unspecified