Provider Demographics
NPI:1285453761
Name:BOTELHO, MANUEL J JR (LADC II #17920)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:J
Last Name:BOTELHO
Suffix:JR
Gender:M
Credentials:LADC II #17920
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2003
Mailing Address - Street 2:
Mailing Address - City:TEATICKET
Mailing Address - State:MA
Mailing Address - Zip Code:02536-2003
Mailing Address - Country:US
Mailing Address - Phone:508-274-0703
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 2003
Practice Address - Street 2:
Practice Address - City:TEATICKET
Practice Address - State:MA
Practice Address - Zip Code:02536-2003
Practice Address - Country:US
Practice Address - Phone:508-274-0703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17920101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)