MEDICARE: DAVID LANTE BOTCHWAY

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1659639714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID LANTE BOTCHWAY

Provider Business Mailing Address
First Line	:	PO BOX 15793
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73155-5793
Country	:	US
Telephone Number	:	405-409-0916
Fax Number	:

Provider Business Practice Location Address
First Line	:	4814 KRISTIE DR APT 74
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73115-4810
Country	:	US
Telephone Number	:	405-409-0916
Fax Number	:

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

Provider Enumeration Date	:	04/26/2012
Last Update Date	:	04/30/2012

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Directions to “ DAVID LANTE BOTCHWAY ” Practice Location

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