=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710798681
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMY BOTTOMLY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2025
-----------------------------------------------------
Last Update Date | 01/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3233 E MEMORIAL RD
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-7082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-361-9599
-----------------------------------------------------
Fax | 405-703-0645
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4824 GREEN COUNTRY RD
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-0900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMY BOTTOMLY
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 405-361-9599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------