1851623821 NPI number — MS. LEORA BETH BOTNICK LCSW

Table of content: MS. LEORA BETH BOTNICK LCSW (NPI 1851623821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851623821 NPI number — MS. LEORA BETH BOTNICK LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOTNICK
Provider First Name:
LEORA
Provider Middle Name:
BETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851623821
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 PELHAM PKWY S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10461-1138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-918-6706
Provider Business Mailing Address Fax Number:
718-918-3480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
234 E 149TH ST
Provider Second Line Business Practice Location Address:
1B2
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10451-5504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-579-5657
Provider Business Practice Location Address Fax Number:
718-579-5310
Provider Enumeration Date:
02/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  076269 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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