Provider Demographics
NPI:1740341866
Name:GOTTLIEB, BRUCE (PH D)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 15TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-6642
Mailing Address - Country:US
Mailing Address - Phone:860-818-4096
Mailing Address - Fax:
Practice Address - Street 1:1732 15TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-6642
Practice Address - Country:US
Practice Address - Phone:860-818-4096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2024-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY200001402103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680000204Medicare ID - Type Unspecified