Provider Demographics
NPI:1003912700
Name:BOTHAM, TRACEY A (LCSW-R)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:A
Last Name:BOTHAM
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-2201
Mailing Address - Country:US
Mailing Address - Phone:716-218-1400
Mailing Address - Fax:716-332-2820
Practice Address - Street 1:425 MAIN ST.
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048
Practice Address - Country:US
Practice Address - Phone:716-366-3533
Practice Address - Fax:716-363-1184
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079070-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker