Provider Demographics
NPI:1326172644
Name:GOTZ, MARIELLA ELLE (PHD, LPC, ATR-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARIELLA
Middle Name:ELLE
Last Name:GOTZ
Suffix:
Gender:F
Credentials:PHD, LPC, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W HAYS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5435
Mailing Address - Country:US
Mailing Address - Phone:208-284-5273
Mailing Address - Fax:
Practice Address - Street 1:1010 W HAYS ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5435
Practice Address - Country:US
Practice Address - Phone:208-284-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3004101YP2500X
IDPSY-202270103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1326172644Medicaid