Provider Demographics
NPI:1386003457
Name:JARAMILLO-BOTERO, MARIA
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:
Last Name:JARAMILLO-BOTERO
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 1:680 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-3825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:680 WILSON AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-3825
Practice Address - Country:US
Practice Address - Phone:415-209-5142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107757106H00000X
CAIMF 92551106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist