Provider Demographics
NPI:1639126378
Name:BOTTENHORN, JAMES J (MA, LLP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:J
Last Name:BOTTENHORN
Suffix:
Gender:M
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3274 PESHTIGO DR SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3018
Mailing Address - Country:US
Mailing Address - Phone:616-249-0939
Mailing Address - Fax:
Practice Address - Street 1:300 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6927
Practice Address - Country:US
Practice Address - Phone:616-455-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007617103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist