Provider Demographics
NPI:1558337410
Name:GOTTLIEB, BRUCE L (LISW-S, LCSW, CCFC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:LISW-S, LCSW, CCFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24075 COMMERCE PARK RD.
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-292-3999
Mailing Address - Fax:
Practice Address - Street 1:24075 COMMERCE PARK
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5846
Practice Address - Country:US
Practice Address - Phone:216-292-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004656A1041C0700X
OHI.0800131-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN237580QQQMedicare ID - Type Unspecified