Provider Demographics
NPI:1316423312
Name:OTT, LYDIA GRACE (ATC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:GRACE
Last Name:OTT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 GREENWICH MILAN TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-8842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:821 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-2415
Practice Address - Country:US
Practice Address - Phone:419-921-9792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer