1942770375 NPI number — MS. DAWN RAE BOTTORFF LCSW-C

Table of content: MS. DAWN RAE BOTTORFF LCSW-C (NPI 1942770375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942770375 NPI number — MS. DAWN RAE BOTTORFF LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOTTORFF
Provider First Name:
DAWN
Provider Middle Name:
RAE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YODER
Provider Other First Name:
DAWN
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942770375
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3706 WHITE PINE RD APT E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21220-3232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-533-2634
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12039 REISTERSTOWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REISTERSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21136-3042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-527-5000
Provider Business Practice Location Address Fax Number:
410-833-4102
Provider Enumeration Date:
11/28/2018

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12648 . This is a "DHMH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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