Provider Demographics
NPI:1104971092
Name:O'BRIEN-BOTTS, ALICE (LMSW)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:O'BRIEN-BOTTS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-1517
Mailing Address - Country:US
Mailing Address - Phone:607-687-1906
Mailing Address - Fax:
Practice Address - Street 1:80 WILLIAM DONNELLY PARKWAY
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:NY
Practice Address - Zip Code:14892
Practice Address - Country:US
Practice Address - Phone:607-565-9594
Practice Address - Fax:607-565-7194
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073875-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00618162Medicaid
NY073875-1OtherLMSW LICENSE NUMBER
NY073875-1OtherLMSW LICENSE NUMBER