MEDICARE: MS. MARY LOU GOTTLIEB

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	1041C0700X	Clinical Social Worker	LCS7439	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LCS7439	OTHER	CA	SOCIAL WORK

General Provider Information

NPI Number	:	1790814580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY LOU GOTTLIEB

Provider Business Mailing Address
First Line	:	16360 ROSCOE BLVD
Second Line	:	2ND FLOOR
City	:	VAN NUYS
State	:	CA
Zip	:	91406-1219
Country	:	US
Telephone Number	:	818-901-4830
Fax Number	:

Provider Business Practice Location Address
First Line	:	16360 ROSCOE BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91406-1219
Country	:	US
Telephone Number	:	818-901-4830
Fax Number	:

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

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/11/2016

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