Basic Information
Provider Information
NPI: 1003140039
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KOTTHA
FirstName: CARMEN
MiddleName: K
NamePrefix:  
NameSuffix:  
Credential: LISW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000XI.0900019OHY Behavioral Health & Social Service ProvidersSocial Worker 

ID Information
IDTypeStateIssuerDescription
026876805OH MEDICAID


Home