Provider Demographics
NPI:1336488790
Name:KOTECKI, NATHAN ALVIN (LLBSW)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ALVIN
Last Name:KOTECKI
Suffix:
Gender:M
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 JEWETT RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-8729
Mailing Address - Country:US
Mailing Address - Phone:517-676-5405
Mailing Address - Fax:517-676-5460
Practice Address - Street 1:507 36TH ST SE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548-2339
Practice Address - Country:US
Practice Address - Phone:616-247-4580
Practice Address - Fax:616-247-4590
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020875791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical