Healthcare Provider Details

I. General information

NPI: 1578923769
Provider Name (Legal Business Name): BOTTS THERAPY AND CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MANHATTAN AVE
JERSEY CITY NJ
07307-3021
US

IV. Provider business mailing address

104 MANHATTAN AVE
JERSEY CITY NJ
07307-3021
US

V. Phone/Fax

Practice location:
  • Phone: 616-893-4519
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05583000
License Number StateNJ

VIII. Authorized Official

Name: MARY BETH BOTTS
Title or Position: MEMBER
Credential: LCSW
Phone: 616-893-4519