Provider Demographics
NPI:1588295232
Name:BOTT, MIRIAM RUTH (LPC)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:RUTH
Last Name:BOTT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 BARTON AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23222-2707
Mailing Address - Country:US
Mailing Address - Phone:616-617-2906
Mailing Address - Fax:
Practice Address - Street 1:6802 PARAGON PL STE 525
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1659
Practice Address - Country:US
Practice Address - Phone:804-592-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008507101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty