Provider Demographics
NPI:1154873883
Name:GOTTLIEB, RISCHA CONNELL (PHD)
Entity type:Individual
Prefix:DR
First Name:RISCHA
Middle Name:CONNELL
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:RISCHA
Other - Last Name:GOTTLIEB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:4807 30TH AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1233
Mailing Address - Country:US
Mailing Address - Phone:917-559-7209
Mailing Address - Fax:
Practice Address - Street 1:4807 30TH AVE
Practice Address - Street 2:APT 1
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-1233
Practice Address - Country:US
Practice Address - Phone:917-559-7209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021912103TB0200X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent