Healthcare Provider Details

I. General information

NPI: 1386314987
Provider Name (Legal Business Name): TEDDY BOTANA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 12/28/2025
Certification Date: 12/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3403 SW 152ND PASS
MIAMI FL
33185-4835
US

IV. Provider business mailing address

2423 SW 147TH AVE # 624
MIAMI FL
33185-4082
US

V. Phone/Fax

Practice location:
  • Phone: 786-496-0569
  • Fax:
Mailing address:
  • Phone: 786-399-4504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT4843
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: