Provider Demographics
NPI:1639101736
Name:BOTTUM, GREGORY ELISHA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ELISHA
Last Name:BOTTUM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2803
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-2803
Mailing Address - Country:US
Mailing Address - Phone:916-797-0695
Mailing Address - Fax:
Practice Address - Street 1:9264 MADISON AVE
Practice Address - Street 2:
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-5858
Practice Address - Country:US
Practice Address - Phone:916-797-0695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 6405103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical