Basic Information
| Provider Information | |||||||||
| NPI: | 1255340642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTICKI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7127 OLD SPRING ST | ||||||||
| Address2: | |||||||||
| City: | RACINE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534063304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2624560707 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1220 MOUND AVE STE 301 | ||||||||
| Address2: | |||||||||
| City: | RACINE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534043350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626333591 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 40910900 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 40910900 | 05 | WI | MEDICAID |