Provider Demographics
NPI:1083232862
Name:BOTSFORD, OLIVIA SUZANNE
Entity Type:Individual
Prefix:MISS
First Name:OLIVIA
Middle Name:SUZANNE
Last Name:BOTSFORD
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 1:2369 NW SCHMIDT WAY APT 117
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4775
Mailing Address - Country:US
Mailing Address - Phone:503-407-7121
Mailing Address - Fax:
Practice Address - Street 1:2369 NW SCHMIDT WAY APT 117
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4775
Practice Address - Country:US
Practice Address - Phone:503-407-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator