Provider Demographics
NPI:1386073773
Name:OTTESEN, EDWARD SCOTT (LPC)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:SCOTT
Last Name:OTTESEN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12471 N 75TH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5208
Mailing Address - Country:US
Mailing Address - Phone:480-882-8059
Mailing Address - Fax:
Practice Address - Street 1:12471 N 75TH DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5208
Practice Address - Country:US
Practice Address - Phone:480-882-8059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2015-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-15869101YP2500X
AZ2077101YA0400X
AZ274970101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2676OtherOBHL BEHAVIOR LICENSURE NUMBER