Provider Demographics
NPI:1821087677
Name:BOTT, PATRICIA (PT)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 LENA ST STE A1
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2002
Mailing Address - Country:US
Mailing Address - Phone:505-982-5868
Mailing Address - Fax:505-995-0500
Practice Address - Street 1:1704 LENA ST STE A1
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2002
Practice Address - Country:US
Practice Address - Phone:505-982-5868
Practice Address - Fax:505-995-0500
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM344517501Medicare ID - Type Unspecified
NM400521225Medicare PIN