Provider Demographics
NPI:1588959480
Name:BOTTA, MARILYN SANDRA (MARILYN BOTTA)
Entity type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:SANDRA
Last Name:BOTTA
Suffix:
Gender:F
Credentials:MARILYN BOTTA
Other - Prefix:MS
Other - First Name:MARILYN
Other - Middle Name:SANDRA
Other - Last Name:BOTTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:304 CALDWELL CIR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-5728
Mailing Address - Country:US
Mailing Address - Phone:706-231-5008
Mailing Address - Fax:
Practice Address - Street 1:304 CALDWELL CIR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-5728
Practice Address - Country:US
Practice Address - Phone:706-231-5008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT006157225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist