MEDICARE: DR. GREGORY ELISHA BOTTUM PSYD

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	103TC0700X	Clinical Psychologist	PSY 6405	CA

General Provider Information

NPI Number	:	1639101736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY ELISHA BOTTUM PSYD

Provider Business Mailing Address
First Line	:	PO BOX 2803
Second Line	:
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-2803
Country	:	US
Telephone Number	:	916-797-0695
Fax Number	:

Provider Business Practice Location Address
First Line	:	9264 MADISON AVE
Second Line	:
City	:	ORANGEVALE
State	:	CA
Zip	:	95662-5858
Country	:	US
Telephone Number	:	916-797-0695
Fax Number	:

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	07/08/2007

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