Provider Demographics
NPI:1922621242
Name:BOTELLO, SUZANNE ANDRY (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:ANDRY
Last Name:BOTELLO
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 W DAYDREAM DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7212
Mailing Address - Country:US
Mailing Address - Phone:928-266-3770
Mailing Address - Fax:
Practice Address - Street 1:1538 W DAYDREAM DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7212
Practice Address - Country:US
Practice Address - Phone:928-266-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4765103TP2701X, 103TC1900X
AZLPC-2539101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03029048OtherTRANSACTION PRIVILEGE TAX NUMBER