Provider Demographics
NPI:1861470403
Name:GOTTLICK, WILLIAM JOSEPH (AUD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOSEPH
Last Name:GOTTLICK
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DR
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:270-412-9110
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-412-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT005923231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN