Provider Demographics
NPI:1528094745
Name:GOTLIEB, TALIA (MA, CCC-A)
Entity type:Individual
Prefix:MS
First Name:TALIA
Middle Name:
Last Name:GOTLIEB
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13-19 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1837
Mailing Address - Country:US
Mailing Address - Phone:201-703-6800
Mailing Address - Fax:201-703-6805
Practice Address - Street 1:13-19 RIVER RD
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1837
Practice Address - Country:US
Practice Address - Phone:201-703-6800
Practice Address - Fax:201-703-6805
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YA00002100231H00000X
NJ25MG00039200237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6126600Medicaid
NJ6126600Medicaid