Provider Demographics
NPI:1093855033
Name:BOTWINICK, ANDREA K (MSED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:K
Last Name:BOTWINICK
Suffix:
Gender:F
Credentials:MSED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ROSEBURG SCOTTISH RITE CLINIC
Mailing Address - Street 2:920 SE CASS, RM. 208
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470
Mailing Address - Country:US
Mailing Address - Phone:541-440-3040
Mailing Address - Fax:
Practice Address - Street 1:ROSEBURG SCOTTISH RITE CLINIC
Practice Address - Street 2:920 SE CASS, RM. 208
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470
Practice Address - Country:US
Practice Address - Phone:541-440-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11241235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR051412Medicaid