Healthcare Provider Details

I. General information

NPI: 1407194665
Provider Name (Legal Business Name): GITELLE KOTLER LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 4TH ST
LAKEWOOD NJ
08701-3228
US

IV. Provider business mailing address

219 8TH ST APT 14A
LAKEWOOD NJ
08701-2831
US

V. Phone/Fax

Practice location:
  • Phone: 216-337-6267
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL05809500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: