Provider Demographics
NPI:1285278572
Name:BOTT, ANDREA ELLIS
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:ELLIS
Last Name:BOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 N 750 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4945
Mailing Address - Country:US
Mailing Address - Phone:435-752-5302
Mailing Address - Fax:
Practice Address - Street 1:2072 N MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1700
Practice Address - Country:US
Practice Address - Phone:435-213-1638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6790474-35021041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical