Provider Demographics
NPI:1194870055
Name:BOTELLO, DINA NOLTE (PSYD)
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:NOLTE
Last Name:BOTELLO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9435 ACHATES CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-5535
Mailing Address - Country:US
Mailing Address - Phone:916-857-0868
Mailing Address - Fax:
Practice Address - Street 1:7486 CENTER PKWY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-3063
Practice Address - Country:US
Practice Address - Phone:916-534-2736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20811103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL208110OtherBLUE SHIELD