Provider Demographics
NPI:1871044388
Name:DR. KATHERINE BOTHOS LLC
Entity Type:Organization
Organization Name:DR. KATHERINE BOTHOS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTHOS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:203-445-3736
Mailing Address - Street 1:170 POST RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6262
Mailing Address - Country:US
Mailing Address - Phone:203-445-3736
Mailing Address - Fax:
Practice Address - Street 1:170 POST RD
Practice Address - Street 2:SUITE 208
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6262
Practice Address - Country:US
Practice Address - Phone:203-445-3736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002950103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008025366Medicaid