Provider Demographics
NPI:1659026250
Name:GOTTERUP, ALEA ELIZABETH
Entity Type:Individual
Prefix:
First Name:ALEA
Middle Name:ELIZABETH
Last Name:GOTTERUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 SEAGULL DR APT 105
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-3464
Mailing Address - Country:US
Mailing Address - Phone:757-277-8738
Mailing Address - Fax:
Practice Address - Street 1:6951 PISTOL RANGE RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-9601
Practice Address - Country:US
Practice Address - Phone:813-696-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician