Provider Demographics
NPI:1306192802
Name:KOTAKE, CHIE (MA)
Entity Type:Individual
Prefix:
First Name:CHIE
Middle Name:
Last Name:KOTAKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CROWNINSHIELD ST
Mailing Address - Street 2:UNIT 111
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-8201
Mailing Address - Country:US
Mailing Address - Phone:781-572-8253
Mailing Address - Fax:
Practice Address - Street 1:148 WARREN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2208
Practice Address - Country:US
Practice Address - Phone:781-572-8253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent