Provider Demographics
NPI:1295147254
Name:BOTTORFF, MISTY (LICSW, LCSW)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:BOTTORFF
Suffix:
Gender:F
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14406 NE 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-1448
Mailing Address - Country:US
Mailing Address - Phone:360-558-2046
Mailing Address - Fax:
Practice Address - Street 1:14406 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1448
Practice Address - Country:US
Practice Address - Phone:360-558-2046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL73711041C0700X
WALW611783941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical