Provider Demographics
NPI:1902242589
Name:BOTTOM, REBECCA LEANN (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEANN
Last Name:BOTTOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 200 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-4942
Mailing Address - Fax:317-962-4343
Practice Address - Street 1:355 W. 16TH STREET
Practice Address - Street 2:DEPT. OF PSYCHIATRY
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2207
Practice Address - Country:US
Practice Address - Phone:317-963-7288
Practice Address - Fax:317-963-7313
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC192262390200000X
IN01078932A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty