Healthcare Provider Details

I. General information

NPI: 1063039147
Provider Name (Legal Business Name): RAE ANN KOTAR NCC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 AIRPORT RD STE 205
LAKEWOOD NJ
08701-5960
US

IV. Provider business mailing address

1001 3RD ST
BADEN PA
15005-1301
US

V. Phone/Fax

Practice location:
  • Phone: 866-625-4740
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC014881
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC014881
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: