Provider Demographics
NPI:1558508390
Name:GOTTLIEB, STEPHEN SIMCHA (LAC, AP)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:SIMCHA
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:LAC, AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 NE 174TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-1234
Mailing Address - Country:US
Mailing Address - Phone:305-904-2688
Mailing Address - Fax:877-350-2321
Practice Address - Street 1:1265 NE 174TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-1234
Practice Address - Country:US
Practice Address - Phone:305-904-2688
Practice Address - Fax:877-350-2321
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2448171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist