Provider Demographics
NPI:1407015381
Name:KOHTALA, LOTTIE (MSW, CAADC)
Entity Type:Individual
Prefix:
First Name:LOTTIE
Middle Name:
Last Name:KOHTALA
Suffix:
Gender:F
Credentials:MSW, CAADC
Other - Prefix:
Other - First Name:LOTTIE
Other - Middle Name:
Other - Last Name:LANCOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, CAADC
Mailing Address - Street 1:200 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4630
Mailing Address - Country:US
Mailing Address - Phone:906-233-1236
Mailing Address - Fax:906-233-1235
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4760
Practice Address - Country:US
Practice Address - Phone:906-774-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010857071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1724945Medicaid