Provider Demographics
NPI:1104123496
Name:GOTTEHRER, CARLY (LPC)
Entity type:Individual
Prefix:MS
First Name:CARLY
Middle Name:
Last Name:GOTTEHRER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1901
Mailing Address - Country:US
Mailing Address - Phone:860-423-7220
Mailing Address - Fax:860-423-7366
Practice Address - Street 1:433 VALLEY ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1901
Practice Address - Country:US
Practice Address - Phone:860-423-7220
Practice Address - Fax:860-423-7366
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002236101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional