MEDICARE: SHERA LEE GOTTLOB CAC I

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1588229942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERA LEE GOTTLOB CAC I

Provider Business Mailing Address
First Line	:	842 HUBBELL DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80911-3523
Country	:	US
Telephone Number	:	719-696-5891
Fax Number	:

Provider Business Practice Location Address
First Line	:	1026 MAXWELL ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-5554
Country	:	US
Telephone Number	:	719-203-6550
Fax Number	:

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

Provider Enumeration Date	:	05/01/2019
Last Update Date	:	05/01/2019

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