Provider Demographics
NPI:1669830329
Name:GOTTLIEB, SHIRA BETH (PSYD)
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:BETH
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N WASHINGTON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3410
Mailing Address - Country:US
Mailing Address - Phone:703-825-0502
Mailing Address - Fax:
Practice Address - Street 1:405 N WASHINGTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3410
Practice Address - Country:US
Practice Address - Phone:703-825-0502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005372103TC2200X
DCPSY1001188103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent