Provider Demographics
NPI:1366128910
Name:BOTELLO-PATINO, JOHN ANDREW
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:BOTELLO-PATINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W 116TH ST APT 6D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-2555
Mailing Address - Country:US
Mailing Address - Phone:909-472-5693
Mailing Address - Fax:
Practice Address - Street 1:858 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-2927
Practice Address - Country:US
Practice Address - Phone:914-879-9657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP121772104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker