Provider Demographics
NPI:1881294338
Name:PAUL J BOTTICELLI LCSW PC
Entity type:Organization
Organization Name:PAUL J BOTTICELLI LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTTICELLI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-689-1728
Mailing Address - Street 1:379 POND PATH
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1020
Mailing Address - Country:US
Mailing Address - Phone:631-987-4817
Mailing Address - Fax:
Practice Address - Street 1:22 SOUTHERN BLVD STE 111
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-1086
Practice Address - Country:US
Practice Address - Phone:631-689-1728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-26
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty