Provider Demographics
NPI:1154409142
Name:LOTTER, SHAUN (MA)
Entity type:Individual
Prefix:MR
First Name:SHAUN
Middle Name:
Last Name:LOTTER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 W RICHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-6018
Mailing Address - Country:US
Mailing Address - Phone:417-343-9939
Mailing Address - Fax:
Practice Address - Street 1:2135 S EASTGATE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-2146
Practice Address - Country:US
Practice Address - Phone:417-221-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006031338101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497205708Medicaid