Provider Demographics
NPI:1689248957
Name:GOTTFRIED, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GOTTFRIED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 SAMPSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ENOSBURG FALLS
Mailing Address - State:VT
Mailing Address - Zip Code:05450-5398
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3303 SAMPSONVILLE RD
Practice Address - Street 2:
Practice Address - City:ENOSBURG FALLS
Practice Address - State:VT
Practice Address - Zip Code:05450-5398
Practice Address - Country:US
Practice Address - Phone:978-771-2863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-18-31-653103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst