Healthcare Provider Details

I. General information

NPI: 1568468312
Provider Name (Legal Business Name): JEFFREY GOTTLIEB PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 CHICAGO AVENUE SOUTH MOB BUILDING, 7TH FLOOR
MINNEAPOLIS MN
55404
US

IV. Provider business mailing address

80 ARTHUR AVENUE SOUTHEAST
MINNEAPOLIS MN
55414-3410
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-4471
  • Fax:
Mailing address:
  • Phone: 651-647-0442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP1651
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: