Provider Demographics
NPI:1659639714
Name:BOTCHWAY, DAVID LANTE
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LANTE
Last Name:BOTCHWAY
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:PO BOX 15793
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73155-5793
Mailing Address - Country:US
Mailing Address - Phone:405-409-0916
Mailing Address - Fax:
Practice Address - Street 1:4814 KRISTIE DR APT 74
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-4810
Practice Address - Country:US
Practice Address - Phone:405-409-0916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health