Provider Demographics
NPI:1124477047
Name:MCCLAIN-OTTO, MINDY NOEL
Entity type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:NOEL
Last Name:MCCLAIN-OTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2795 FLORESTA DR NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5522
Mailing Address - Country:US
Mailing Address - Phone:321-508-4393
Mailing Address - Fax:
Practice Address - Street 1:2050 40TH AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32968-2467
Practice Address - Country:US
Practice Address - Phone:772-567-0061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI2833235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist