Provider Demographics
NPI:1720538598
Name:GOTLIB, TAMEMA LEAH
Entity Type:Individual
Prefix:MRS
First Name:TAMEMA
Middle Name:LEAH
Last Name:GOTLIB
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 1:12 KEW GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-7101
Mailing Address - Country:US
Mailing Address - Phone:732-363-4713
Mailing Address - Fax:
Practice Address - Street 1:12 KEW GARDENS DR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-7101
Practice Address - Country:US
Practice Address - Phone:732-363-4713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ908018103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool