Provider Demographics
NPI:1972879237
Name:GOTTLIEB, BURTON DAVID (MA LMSW)
Entity type:Individual
Prefix:MR
First Name:BURTON
Middle Name:DAVID
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:MA LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 MAPLEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SYLVAN LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1737
Mailing Address - Country:US
Mailing Address - Phone:258-941-7800
Mailing Address - Fax:
Practice Address - Street 1:28000 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2468
Practice Address - Country:US
Practice Address - Phone:586-753-1028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010604681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical