Provider Demographics
NPI:1013460005
Name:BOTT, BARTON (MH)
Entity Type:Individual
Prefix:MR
First Name:BARTON
Middle Name:
Last Name:BOTT
Suffix:
Gender:M
Credentials:MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2478 1ST AVE
Mailing Address - Street 2:A
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-6386
Mailing Address - Country:US
Mailing Address - Phone:904-432-8603
Mailing Address - Fax:
Practice Address - Street 1:910 S 8TH ST
Practice Address - Street 2:SUITE 121
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3744
Practice Address - Country:US
Practice Address - Phone:904-432-8603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6275101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherDO NOT WORK WITH THESE ISSUERS