Provider Demographics
NPI:1225169873
Name:BOTA, ANDJELKO (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ANDJELKO
Middle Name:
Last Name:BOTA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3085 36TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4704
Mailing Address - Country:US
Mailing Address - Phone:718-726-5152
Mailing Address - Fax:718-728-1527
Practice Address - Street 1:3085 36TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4704
Practice Address - Country:US
Practice Address - Phone:718-726-5152
Practice Address - Fax:718-728-1527
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR046981-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01585Medicare ID - Type Unspecified