Provider Demographics
NPI:1780733774
Name:BOTTORFF, NANCY K (LP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:K
Last Name:BOTTORFF
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3927 THOMAS AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1235
Mailing Address - Country:US
Mailing Address - Phone:612-207-0090
Mailing Address - Fax:
Practice Address - Street 1:3108 HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2619
Practice Address - Country:US
Practice Address - Phone:612-590-7572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-1910103T00000X
MNLP4674103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist