Provider Demographics
NPI:1023178969
Name:BOTMA, SARA LYNN
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:LYNN
Last Name:BOTMA
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 1:490 E KENT AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-1242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:793 N ALMA SCHOOL RD
Practice Address - Street 2:SUITE D4
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-3681
Practice Address - Country:US
Practice Address - Phone:480-626-4142
Practice Address - Fax:480-626-7370
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP2108235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ724056Medicaid