Provider Demographics
NPI:1528185279
Name:GOTWALT, ROBERT W (MS CCDP DIPLOMATE)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:W
Last Name:GOTWALT
Suffix:
Gender:M
Credentials:MS CCDP DIPLOMATE
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 2675
Mailing Address - Street 2:DPW-OMHSAS LOGAN BUILDING
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17105-2675
Mailing Address - Country:US
Mailing Address - Phone:717-772-7513
Mailing Address - Fax:
Practice Address - Street 1:120 EAST AZALEA DRIVE
Practice Address - Street 2:
Practice Address - City:HBG.
Practice Address - State:PA
Practice Address - Zip Code:17110-3594
Practice Address - Country:US
Practice Address - Phone:717-772-7513
Practice Address - Fax:717-772-7699
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACERT.# 6218101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)