Provider Demographics
NPI:1790814580
Name:GOTTLIEB, MARY LOU
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOU
Last Name:GOTTLIEB
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 1:16360 ROSCOE BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-1219
Mailing Address - Country:US
Mailing Address - Phone:818-901-4830
Mailing Address - Fax:
Practice Address - Street 1:16360 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-1219
Practice Address - Country:US
Practice Address - Phone:818-901-4830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS74391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS7439OtherSOCIAL WORK