Healthcare Provider Details

I. General information

NPI: 1922621242
Provider Name (Legal Business Name): SUZANNE ANDRY BOTELLO PHD, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1538 W DAYDREAM DR
FLAGSTAFF AZ
86001-7212
US

IV. Provider business mailing address

1538 W DAYDREAM DR
FLAGSTAFF AZ
86001-7212
US

V. Phone/Fax

Practice location:
  • Phone: 928-266-3770
  • Fax:
Mailing address:
  • Phone: 928-266-3770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-2539
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4765
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number4765
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: