Provider Demographics
NPI:1376351478
Name:BOTTINELLI, ANTONIA ALENA
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:ALENA
Last Name:BOTTINELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 OLDE TOWNE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-5646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4901 OLDE TOWNE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-5646
Practice Address - Country:US
Practice Address - Phone:678-580-3997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty