Provider Demographics
NPI:1043340615
Name:BOTELLO, TAMMY LYNN (LPC)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYNN
Last Name:BOTELLO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 W PIONEER PKWY
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-6367
Mailing Address - Country:US
Mailing Address - Phone:817-538-5998
Mailing Address - Fax:817-549-7139
Practice Address - Street 1:1122 W PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-6367
Practice Address - Country:US
Practice Address - Phone:817-538-5998
Practice Address - Fax:817-549-7139
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19232101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169897902Medicaid