Healthcare Provider Details

I. General information

NPI: 1497946305
Provider Name (Legal Business Name): SUSAN JACQUELINE KOTLER PH.D, ABPP/ABCN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E JOHN ST
CARSON CITY NV
89706-3039
US

IV. Provider business mailing address

PO BOX 1657
CARSON CITY NV
89702-1657
US

V. Phone/Fax

Practice location:
  • Phone: 775-671-5080
  • Fax:
Mailing address:
  • Phone: 775-671-5080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY0533
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPY0533
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0533
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: