Provider Demographics
NPI:1063552693
Name:BOTNICK, HEIDI L (LAC)
Entity type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:L
Last Name:BOTNICK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:299 ADELPHI ST APT 312
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-4649
Mailing Address - Country:US
Mailing Address - Phone:917-596-0912
Mailing Address - Fax:
Practice Address - Street 1:130 W 57TH ST APT 9E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3311
Practice Address - Country:US
Practice Address - Phone:212-489-8082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029405171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist