Basic Information
| Provider Information | |||||||||
| NPI: | 1003140039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOTTHA | ||||||||
| FirstName: | CARMEN | ||||||||
| MiddleName: | K | ||||||||
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| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24800 CHAGRIN BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162456231 | ||||||||
| FaxNumber: | 2162456351 | ||||||||
| Practice Location | |||||||||
| Address1: | 24800 CHAGRIN BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162456231 | ||||||||
| FaxNumber: | 2162456351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2009 | ||||||||
| LastUpdateDate: | 03/07/2016 | ||||||||
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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 | 104100000X | I.0900019 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0268768 | 05 | OH | MEDICAID |