Provider Demographics
NPI:1780101667
Name:BOTKIN, MARY L (LIMHP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:BOTKIN
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:MARGO
Other - Middle Name:
Other - Last Name:LORIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1629 S 154TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5152
Mailing Address - Country:US
Mailing Address - Phone:708-408-4158
Mailing Address - Fax:
Practice Address - Street 1:3610 N 163RD PLZ # 205
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-2164
Practice Address - Country:US
Practice Address - Phone:708-408-4158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10909101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health