Provider Demographics
NPI:1558485540
Name:BOTKO, MICHELLE JEANNE (MA)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:JEANNE
Last Name:BOTKO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8800 SE SUNNYSIDE RD STE 300N
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5703
Mailing Address - Country:US
Mailing Address - Phone:281-286-2999
Mailing Address - Fax:612-607-4893
Practice Address - Street 1:1560 BEAM AVE STE 101
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1191
Practice Address - Country:US
Practice Address - Phone:651-777-7837
Practice Address - Fax:651-777-8754
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN237600000X, 237700000X
MN6249231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN640000549OtherMEDICARE