Provider Demographics
NPI:1437360369
Name:BOTENS, DEBRA DORFMAN (PHD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:DORFMAN
Last Name:BOTENS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 SCOFIELD PL
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06855-1438
Mailing Address - Country:US
Mailing Address - Phone:203-854-5336
Mailing Address - Fax:
Practice Address - Street 1:47 LONG LOTS ROAD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-3800
Practice Address - Country:US
Practice Address - Phone:203-221-8801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002775103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013033-1OtherLICENSE PSYCHOLOGIST