Provider Demographics
NPI:1972699445
Name:BOTT, WILLIAM RUSSELL (MSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:RUSSELL
Last Name:BOTT
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SHERRY ST
Mailing Address - Street 2:
Mailing Address - City:MACKINAW
Mailing Address - State:IL
Mailing Address - Zip Code:61755
Mailing Address - Country:US
Mailing Address - Phone:309-497-0790
Mailing Address - Fax:309-497-3564
Practice Address - Street 1:411 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605
Practice Address - Country:US
Practice Address - Phone:309-497-0790
Practice Address - Fax:309-497-3564
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker