Provider Demographics
NPI:1265034318
Name:GOTTLIEB, MORDECHAI (LMSW)
Entity type:Individual
Prefix:
First Name:MORDECHAI
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16601 N 40TH ST STE 216
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3354
Mailing Address - Country:US
Mailing Address - Phone:347-461-6426
Mailing Address - Fax:
Practice Address - Street 1:16601 N 40TH ST STE 216
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3354
Practice Address - Country:US
Practice Address - Phone:480-447-9115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-223201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical