Provider Demographics
NPI:1316110471
Name:BOTINELLY, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:BOTINELLY
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:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-0688
Mailing Address - Country:US
Mailing Address - Phone:620-331-1748
Mailing Address - Fax:620-331-1748
Practice Address - Street 1:1604 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3334
Practice Address - Country:US
Practice Address - Phone:620-251-8180
Practice Address - Fax:620-251-8180
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCAC 467101YA0400X
KS147106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)