Healthcare Provider Details

I. General information

NPI: 1497214456
Provider Name (Legal Business Name): HEATHER KOTLERLCSW MPH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 CHURCH ST STE 109
DECATUR GA
30030-3330
US

IV. Provider business mailing address

215 CHURCH ST STE 109
DECATUR GA
30030-3330
US

V. Phone/Fax

Practice location:
  • Phone: 404-798-7228
  • Fax:
Mailing address:
  • Phone: 404-798-7228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HEATHER I KOTLER
Title or Position: OFFICER
Credential: LCSW MPH
Phone: 404-798-7228