MEDICARE: DR. ELIZABETH BOTZER PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	016059-1	NY
2	103T00000X	Psychologist	016059	NY

General Provider Information

NPI Number	:	1063414423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH BOTZER PH.D.

Provider Business Mailing Address
First Line	:	4373 CHESTNUT RD
Second Line	:
City	:	WILSON
State	:	NY
Zip	:	14172
Country	:	US
Telephone Number	:	716-867-0280
Fax Number	:	716-636-4501

Provider Business Practice Location Address
First Line	:	4373 CHESTNUT RD
Second Line	:
City	:	WILSON
State	:	NY
Zip	:	14172
Country	:	US
Telephone Number	:	716-867-0280
Fax Number	:	716-636-4501

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	12/10/2015

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