Provider Demographics
NPI:1316178403
Name:BOTTORFF, MARY ELIZA (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZA
Last Name:BOTTORFF
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:WINKELMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:411 E BROADWAY
Mailing Address - Street 2:COLUMBIA
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-4437
Mailing Address - Country:US
Mailing Address - Phone:573-886-7411
Mailing Address - Fax:573-443-7246
Practice Address - Street 1:411 E BROADWAY
Practice Address - Street 2:COLUMBIA
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-4437
Practice Address - Country:US
Practice Address - Phone:573-886-7411
Practice Address - Fax:573-443-7246
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009022345225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO145960001OtherMEDICARE PTAN