Provider Demographics
NPI:1992152516
Name:GOTTSHALK, LUCILLE
Entity type:Individual
Prefix:
First Name:LUCILLE
Middle Name:
Last Name:GOTTSHALK
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 1:12222 191ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1055
Mailing Address - Country:US
Mailing Address - Phone:646-248-8494
Mailing Address - Fax:
Practice Address - Street 1:3071 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1207
Practice Address - Country:US
Practice Address - Phone:646-248-8494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL233696251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010887300Medicaid