Provider Demographics
NPI:1376689968
Name:ROBERT BOTTINELLI PHD PC
Entity Type:Organization
Organization Name:ROBERT BOTTINELLI PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PROFESSIONAL CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOTTINELLI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:810-230-2800
Mailing Address - Street 1:2187 S DYE RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532
Mailing Address - Country:US
Mailing Address - Phone:810-230-2800
Mailing Address - Fax:
Practice Address - Street 1:2187 S DYE RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532
Practice Address - Country:US
Practice Address - Phone:810-230-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001854103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty