Basic Information
| Provider Information | |||||||||
| NPI: | 1316239809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOTTLIEB | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LEE BARROCAS | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 N CHARLES ST | ||||||||
| Address2: | BALTIMORE | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212046819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109383000 | ||||||||
| FaxNumber: | 4109385131 | ||||||||
| Practice Location | |||||||||
| Address1: | 6501 N CHARLES ST | ||||||||
| Address2: | BALTIMORE | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212046819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109383000 | ||||||||
| FaxNumber: | 4109385131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2011 | ||||||||
| LastUpdateDate: | 08/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 05810 | MD | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.