Provider Demographics
NPI:1255469573
Name:GOTTLIEB, RICHARD F (MSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:F
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 FULTON ST E STE 222
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3262
Mailing Address - Country:US
Mailing Address - Phone:616-774-9000
Mailing Address - Fax:
Practice Address - Street 1:233 FULTON ST E STE 222
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3262
Practice Address - Country:US
Practice Address - Phone:616-774-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010089321041C0700X, 225C00000X
MI4101005165106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor