Provider Demographics
NPI:1932294790
Name:GOTTLICH, ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:GOTTLICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:WALDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:665 E LAKE FRONT CIR
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-3314
Mailing Address - Country:US
Mailing Address - Phone:609-652-8809
Mailing Address - Fax:
Practice Address - Street 1:600 NEW RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-1653
Practice Address - Country:US
Practice Address - Phone:609-641-2500
Practice Address - Fax:609-641-2502
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC000393001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJSO3258Medicare UPIN
NJ651012NK5Medicare ID - Type Unspecified