Healthcare Provider Details

I. General information

NPI: 1619852449
Provider Name (Legal Business Name): LAURIE GOTTLIEB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/11/2025
Certification Date: 08/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 BOLINAS RD STE 5
FAIRFAX CA
94930-1626
US

IV. Provider business mailing address

159 W OAK KNOLL DR
SAN ANSELMO CA
94960-1175
US

V. Phone/Fax

Practice location:
  • Phone: 415-760-6108
  • Fax: 888-226-7020
Mailing address:
  • Phone: 415-760-6108
  • Fax: 415-760-6108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: