Provider Demographics
NPI:1225119456
Name:BOTTUM-MORGAN, EDWIN B (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:B
Last Name:BOTTUM-MORGAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 TAMAL PLZ STE 195
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1181
Mailing Address - Country:US
Mailing Address - Phone:415-927-4800
Mailing Address - Fax:
Practice Address - Street 1:100 TAMAL PLZ STE 195
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1181
Practice Address - Country:US
Practice Address - Phone:415-927-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9703103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical