Provider Demographics
NPI:1023224441
Name:BOTTI, PETER JOSEPH (LISW)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JOSEPH
Last Name:BOTTI
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:1207 W STATE ST STE M
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4686
Practice Address - Country:US
Practice Address - Phone:330-821-8407
Practice Address - Fax:330-821-8506
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.011280101YA0400X
OHI. 00076871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0332237Medicaid