Healthcare Provider Details

I. General information

NPI: 1336024975
Provider Name (Legal Business Name): AMY BOTTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 W HARRIS AVE STE 17
LA GRANGE IL
60525-2368
US

IV. Provider business mailing address

15 W HARRIS AVE STE 17
LA GRANGE IL
60525-2368
US

V. Phone/Fax

Practice location:
  • Phone: 779-429-6513
  • Fax:
Mailing address:
  • Phone: 779-429-6513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: