Provider Demographics
NPI:1396799755
Name:GOTLIB, LORRAINE BETWENIK (RNCS)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:BETWENIK
Last Name:GOTLIB
Suffix:
Gender:F
Credentials:RNCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8051
Mailing Address - Fax:
Practice Address - Street 1:40 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2705
Practice Address - Country:US
Practice Address - Phone:617-629-6180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA116590163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPN0623OtherBLUE CROSS
MA669498OtherTUFTS HEALTH PLAN
MAP00087776OtherMEDICARE RAILROAD
MA0037006OtherNEIGHBORHOOD HEALTH PLAN
MA0037006OtherNEIGHBORHOOD HEALTH PLAN