MEDICARE: GITELLE KOTLER LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	44SL05809500	NJ

General Provider Information

NPI Number	:	1407194665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GITELLE KOTLER LSW

Provider Business Mailing Address
First Line	:	219 8TH ST APT 14A
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-2831
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	225 4TH ST
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-3228
Country	:	US
Telephone Number	:	216-337-6267
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2013
Last Update Date	:	01/23/2013

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