Healthcare Provider Details

I. General information

NPI: 1326781519
Provider Name (Legal Business Name): ROBERT ANTHONY BOTTALLA JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 N GREEN BAY AVE
GLENDALE WI
53209-2800
US

IV. Provider business mailing address

405 BISHOPS WAY UNIT 633
BROOKFIELD WI
53005-6261
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-6187
  • Fax:
Mailing address:
  • Phone: 847-899-7653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1463-140
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: