Provider Demographics
NPI:1295302818
Name:BOTANA, SUZANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:
Last Name:BOTANA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BROOKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4607
Mailing Address - Country:US
Mailing Address - Phone:219-873-4245
Mailing Address - Fax:
Practice Address - Street 1:18 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-2110
Practice Address - Country:US
Practice Address - Phone:207-282-8280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool