Healthcare Provider Details

I. General information

NPI: 1144424334
Provider Name (Legal Business Name): GWEN H KOTLER MSW,LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 09/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 N NOVA RD SUITE 203
ORMOND BEACH FL
32174-4447
US

IV. Provider business mailing address

27 BLACK PINE WAY
ORMOND BEACH FL
32174-1863
US

V. Phone/Fax

Practice location:
  • Phone: 386-334-8430
  • Fax:
Mailing address:
  • Phone: 386-671-7738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 7398
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: