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General NPI Number Information
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NPI Number | 1568468312
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Entity Type | Individual
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Provider Name | JEFFREY GOTTLIEB PH.D.
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Gender | Male
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Dates
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Enumeration Date | 06/27/2005
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Last Update Date | 03/20/2015
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Provider Practice Location Address
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Address Line | 2545 CHICAGO AVENUE SOUTH MOB BUILDING, 7TH FLOOR
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City | MINNEAPOLIS
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State | MN
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Zip | 55404
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Country | US
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Telephone | 612-863-4471
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Fax |
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Provider Business Mailing Address
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Address Line | 80 ARTHUR AVENUE SOUTHEAST
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City | MINNEAPOLIS
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State | MN
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Zip | 55414-3410
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Country | US
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Telephone | 651-647-0442
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP1651
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License Number State | MN
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