Provider Demographics
NPI:1164927877
Name:BOTTEGAL, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BOTTEGAL
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 1:964 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-9363
Mailing Address - Country:US
Mailing Address - Phone:330-424-1468
Mailing Address - Fax:330-424-9844
Practice Address - Street 1:1010 N 6TH AVE
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-1846
Practice Address - Country:US
Practice Address - Phone:330-424-1468
Practice Address - Fax:330-424-9844
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$OtherOHIO SOCIAL SECURITY NUMBER