=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033438015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. KATHERINE BOTHOS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2010
-----------------------------------------------------
Last Update Date | 07/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 POST RD STE 208
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-6242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-455-3736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 704 THORME ST
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06606-4022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-838-8344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. KATHERINE BOTHOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-838-8344
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 002950
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------