Provider Demographics
NPI:1659655280
Name:GOTTLIEB, MICHELLE G (PSYD, MFT)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:G
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:PSYD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N HARBOR BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1990
Mailing Address - Country:US
Mailing Address - Phone:714-879-5868
Mailing Address - Fax:714-879-5858
Practice Address - Street 1:305 N HARBOR BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1990
Practice Address - Country:US
Practice Address - Phone:714-879-5868
Practice Address - Fax:714-879-5858
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32271101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC32271OtherLICENSE NUMBER