Provider Demographics
NPI:1467867499
Name:GOTTLIEB, MICHAEL (ME)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:ME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 1/2 CORINTH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3440
Mailing Address - Country:US
Mailing Address - Phone:310-496-4826
Mailing Address - Fax:
Practice Address - Street 1:3724 1/2 CORINTH AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3440
Practice Address - Country:US
Practice Address - Phone:310-496-4826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-28
Last Update Date:2014-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD3213930103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst