Provider Demographics
NPI:1104940105
Name:GOTTLIEB, MICHAEL C (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12810 HILLCREST RD
Mailing Address - Street 2:B224
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-1525
Mailing Address - Country:US
Mailing Address - Phone:972-661-0746
Mailing Address - Fax:972-385-0093
Practice Address - Street 1:12810 HILLCREST RD
Practice Address - Street 2:B224
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-1525
Practice Address - Country:US
Practice Address - Phone:972-661-0746
Practice Address - Fax:972-385-0093
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20987103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00CH96Medicare ID - Type Unspecified