Provider Demographics
NPI:1023175171
Name:BOTELLO, SUSAN MARY (MSW, LICSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARY
Last Name:BOTELLO
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 MILLWAY
Mailing Address - Street 2:P.O. BOX 1030
Mailing Address - City:BARNSTABLE
Mailing Address - State:MA
Mailing Address - Zip Code:02630-1102
Mailing Address - Country:US
Mailing Address - Phone:508-375-0080
Mailing Address - Fax:508-375-0083
Practice Address - Street 1:275 MILLWAY
Practice Address - Street 2:
Practice Address - City:BARNSTABLE
Practice Address - State:MA
Practice Address - Zip Code:02630-1102
Practice Address - Country:US
Practice Address - Phone:508-375-0080
Practice Address - Fax:508-375-0083
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1103101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical