Provider Demographics
NPI:1356613111
Name:GOTTESMAN, LISA BROOKE (LCSW)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:BROOKE
Last Name:GOTTESMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3143
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-0293
Mailing Address - Country:US
Mailing Address - Phone:267-825-7458
Mailing Address - Fax:
Practice Address - Street 1:104 MEWS LN
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2629
Practice Address - Country:US
Practice Address - Phone:609-529-3439
Practice Address - Fax:267-285-4336
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0172271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007283430002Medicaid