Provider Demographics
NPI:1528513785
Name:OTT, THOMAS (LLP)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:OTT
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W FERRY ST
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1109
Mailing Address - Country:US
Mailing Address - Phone:269-815-5331
Mailing Address - Fax:
Practice Address - Street 1:300 W FERRY ST
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1109
Practice Address - Country:US
Practice Address - Phone:269-815-5331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008124103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical