Provider Demographics
NPI:1104888569
Name:GOTTLOB CULLEN, LOUISE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LOUISE
Middle Name:
Last Name:GOTTLOB CULLEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LOUISE
Other - Middle Name:J
Other - Last Name:CULLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35000 CHARDON RD #210
Mailing Address - Street 2:DIANE EDEN MD AND ASSOC.
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094
Mailing Address - Country:US
Mailing Address - Phone:440-951-5600
Mailing Address - Fax:440-951-1293
Practice Address - Street 1:35000 CHARDON RD #210
Practice Address - Street 2:DIANE EDEN MD AND ASSOC.
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-951-5600
Practice Address - Fax:440-951-1293
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7128104100000X
AZLISW-192361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGOSW22921Medicare ID - Type Unspecified