Provider Demographics
NPI:1063030658
Name:BOTVINNIK, MICHELLE ELLA
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELLA
Last Name:BOTVINNIK
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 1:2814 W 8TH ST APT 15B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-3368
Mailing Address - Country:US
Mailing Address - Phone:646-872-6555
Mailing Address - Fax:
Practice Address - Street 1:6002 FARRAGUT RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3125
Practice Address - Country:US
Practice Address - Phone:718-209-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst