Basic Information
| Provider Information | |||||||||
| NPI: | 1699338475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOTTSHALL | ||||||||
| FirstName: | KEMPER | ||||||||
| MiddleName: | IAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 S GRAND AVE BLDG C2 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927054434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145677681 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 S GRAND AVE BLDG C2 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927054434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145677681 | ||||||||
| FaxNumber: | 7145675140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2019 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.