Healthcare Provider Details

I. General information

NPI: 1205428901
Provider Name (Legal Business Name): ELIZABETH JAN KOTKIN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3237 PHILIP AVE
BRONX NY
10465-1661
US

IV. Provider business mailing address

3237 PHILIP AVE
BRONX NY
10465-1661
US

V. Phone/Fax

Practice location:
  • Phone: 646-703-4359
  • Fax:
Mailing address:
  • Phone: 646-703-4359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000974
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: