Provider Demographics
NPI:1942395306
Name:GOTTLIEB, DAVID EDMUND (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDMUND
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 HICKORY RD.
Mailing Address - Street 2:STE. 104
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2125
Mailing Address - Country:US
Mailing Address - Phone:708-799-8796
Mailing Address - Fax:708-799-6409
Practice Address - Street 1:2024 HICKORY RD.
Practice Address - Street 2:STE. 104
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2125
Practice Address - Country:US
Practice Address - Phone:708-799-8796
Practice Address - Fax:708-799-6409
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01672899OtherBCBS ID
IL01672899OtherBCBS ID