Provider Demographics
NPI:1356580351
Name:BOTONJIC, OSMAN
Entity type:Individual
Prefix:
First Name:OSMAN
Middle Name:
Last Name:BOTONJIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 STORRS RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1683
Mailing Address - Country:US
Mailing Address - Phone:860-963-6416
Mailing Address - Fax:860-963-6303
Practice Address - Street 1:189 STORRS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1683
Practice Address - Country:US
Practice Address - Phone:860-963-6416
Practice Address - Fax:860-963-6303
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-13
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00974101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional