Provider Demographics
NPI:1114050259
Name:BOTTIN, LARRY FRED (MSW LICSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:FRED
Last Name:BOTTIN
Suffix:
Gender:M
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13008 W 102ND TERRACE
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:62215
Mailing Address - Country:US
Mailing Address - Phone:913-307-0155
Mailing Address - Fax:816-922-3317
Practice Address - Street 1:4801 LINWOOD BOULEVARD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64128
Practice Address - Country:US
Practice Address - Phone:816-861-4700
Practice Address - Fax:816-922-3317
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070006151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical