Provider Demographics
NPI:1275735557
Name:BOTMAN, HARVEY IRWIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:HARVEY
Middle Name:IRWIN
Last Name:BOTMAN
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 1:4 HAYWARD AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-7211
Mailing Address - Country:US
Mailing Address - Phone:781-863-2612
Mailing Address - Fax:
Practice Address - Street 1:SUITE 3
Practice Address - Street 2:15 DEPOT SQUARE
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-6330
Practice Address - Country:US
Practice Address - Phone:617-429-1882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4176103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist