Provider Demographics
NPI:1497337190
Name:BOTTS, CHRISTINA LEAH
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:LEAH
Last Name:BOTTS
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 1:5040 HOLLY LN N UNIT 8
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-1759
Mailing Address - Country:US
Mailing Address - Phone:612-205-6640
Mailing Address - Fax:
Practice Address - Street 1:710 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2612
Practice Address - Country:US
Practice Address - Phone:612-615-9821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor