Provider Demographics
NPI:1114188554
Name:BOTKIN, WALTER WADE III (LMHC)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:WADE
Last Name:BOTKIN
Suffix:III
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 BAHIA VISTA ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2635
Mailing Address - Country:US
Mailing Address - Phone:941-812-5321
Mailing Address - Fax:
Practice Address - Street 1:2650 BAHIA VISTA ST
Practice Address - Street 2:SUITE 106
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2635
Practice Address - Country:US
Practice Address - Phone:941-812-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9485101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ167YOtherBLUE CROSS BLUE SHIELD OF FLORIDA