Provider Demographics
NPI:1215266648
Name:GOTTSCHALK, JUDITH (LPC)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:
Last Name:GOTTSCHALK
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:PO BOX 85091
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-5091
Mailing Address - Country:US
Mailing Address - Phone:907-455-4117
Mailing Address - Fax:
Practice Address - Street 1:2737 BONANZA TRAIL
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99708-5091
Practice Address - Country:US
Practice Address - Phone:907-455-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK104101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor