Provider Demographics
NPI:1235747635
Name:MATOS BOTTA, NEODANYS
Entity Type:Individual
Prefix:
First Name:NEODANYS
Middle Name:
Last Name:MATOS BOTTA
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 1:307 MORGAN CIR N
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-7133
Mailing Address - Country:US
Mailing Address - Phone:786-325-2582
Mailing Address - Fax:
Practice Address - Street 1:307 MORGAN CIR N
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-7133
Practice Address - Country:US
Practice Address - Phone:786-325-2582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-127223106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty