Provider Demographics
NPI:1184357089
Name:BOTTS, CYNTHIA LEE (SUDP)
Entity type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:LEE
Last Name:BOTTS
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:LEE
Other - Last Name:RALPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5007 NE ST JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-2348
Mailing Address - Country:US
Mailing Address - Phone:360-687-0693
Mailing Address - Fax:360-666-8601
Practice Address - Street 1:5007 NE ST JOHNS RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-2348
Practice Address - Country:US
Practice Address - Phone:360-687-0693
Practice Address - Fax:360-666-8601
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61067094101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)