Provider Demographics
NPI:1124370127
Name:BOTTA, JEFFREY SAMUEL (DPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SAMUEL
Last Name:BOTTA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 MIDDLEWAY PIKE
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25428-4051
Mailing Address - Country:US
Mailing Address - Phone:304-229-4141
Mailing Address - Fax:304-229-4143
Practice Address - Street 1:745 MIDDLEWAY PIKE
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:WV
Practice Address - Zip Code:25428-4051
Practice Address - Country:US
Practice Address - Phone:304-229-4141
Practice Address - Fax:304-229-4143
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT003080225100000X
VA2305206652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist