Provider Demographics
NPI:1982775763
Name:GOTTLIEB, DIANE T (MSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:T
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:MSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 SAINT PAUL ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4689
Mailing Address - Country:US
Mailing Address - Phone:802-863-2495
Mailing Address - Fax:802-865-0534
Practice Address - Street 1:187 SAINT PAUL ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4689
Practice Address - Country:US
Practice Address - Phone:802-863-2495
Practice Address - Fax:802-865-0534
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT478103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT011764OtherTRICARE VALUE OPTIONS
VT1003835Medicaid
VTT000511OtherCHAMPUS TRICARE
MA01260007OtherMAGELLEN MASS
VT108058OtherUNITED BEHAVIORAL HEALTH
VT223960OtherCOMPSYCH
VT64071OtherCIGNA
VT8064OtherBC AND BS
VTVT9696Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID