MEDICARE: ROBERT ANTHONY BOTTALLA JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1463-140	WI

General Provider Information

NPI Number	:	1326781519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT ANTHONY BOTTALLA JR.

Provider Business Mailing Address
First Line	:	405 BISHOPS WAY UNIT 633
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53005-6261
Country	:	US
Telephone Number	:	847-899-7653
Fax Number	:

Provider Business Practice Location Address
First Line	:	7101 N GREEN BAY AVE
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53209-2800
Country	:	US
Telephone Number	:	414-288-6187
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2022
Last Update Date	:	12/01/2025

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