Provider Demographics
NPI:1679316558
Name:BOTTA, BRIANNE
Entity type:Individual
Prefix:
First Name:BRIANNE
Middle Name:
Last Name:BOTTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LAURA DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10918-2516
Mailing Address - Country:US
Mailing Address - Phone:845-544-5678
Mailing Address - Fax:
Practice Address - Street 1:534 ROUTE 6
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-4746
Practice Address - Country:US
Practice Address - Phone:914-419-5267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028708225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist