MEDICARE: MRS. KATHY BOTTROFF LPC

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	101YP2500X	Professional Counselor	866	OK

General Provider Information

NPI Number	:	1902376932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHY BOTTROFF LPC

Provider Business Mailing Address
First Line	:	3033 NW 63RD ST STE 101
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-3607
Country	:	US
Telephone Number	:	405-948-7767
Fax Number	:

Provider Business Practice Location Address
First Line	:	3033 NW 63RD ST STE 101
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-3607
Country	:	US
Telephone Number	:	405-948-7767
Fax Number	:

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

Provider Enumeration Date	:	12/03/2018
Last Update Date	:	12/03/2018

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