Provider Demographics
NPI:1700204864
Name:GOTTSCHALK, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GOTTSCHALK
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 1:282 S CAMINO DEL PUEBLO
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-5909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 ALLEN ST
Practice Address - Street 2:
Practice Address - City:ESTANCIA
Practice Address - State:NM
Practice Address - Zip Code:87061
Practice Address - Country:US
Practice Address - Phone:505-510-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator