Provider Demographics
NPI:1962015248
Name:GOTTLIEB, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 E 14TH ST APT 1625
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3124
Mailing Address - Country:US
Mailing Address - Phone:917-679-1003
Mailing Address - Fax:
Practice Address - Street 1:285 LIVINGSTON ST FL 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1006
Practice Address - Country:US
Practice Address - Phone:718-935-9201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)