Provider Demographics
NPI:1518600402
Name:ANDREA BOTWINICK
Entity Type:Organization
Organization Name:ANDREA BOTWINICK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTWINICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-580-4686
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97462-0638
Mailing Address - Country:US
Mailing Address - Phone:541-680-4686
Mailing Address - Fax:541-680-4686
Practice Address - Street 1:214 SE 5TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:OR
Practice Address - Zip Code:97462-0139
Practice Address - Country:US
Practice Address - Phone:541-680-4686
Practice Address - Fax:541-680-4686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR051412Medicaid