Provider Demographics
NPI:1255340642
Name:BOTICKI, MICHAEL ALLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:BOTICKI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7127 OLD SPRING ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3304
Mailing Address - Country:US
Mailing Address - Phone:262-456-0707
Mailing Address - Fax:
Practice Address - Street 1:1220 MOUND AVE STE 301
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-3350
Practice Address - Country:US
Practice Address - Phone:262-633-3591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40910900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40910900Medicaid