Provider Demographics
NPI:1598884140
Name:OTTO, KRYSTEL DAWN (MS,ATC, LAT)
Entity type:Individual
Prefix:
First Name:KRYSTEL
Middle Name:DAWN
Last Name:OTTO
Suffix:
Gender:F
Credentials:MS,ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14104 ROSELAWN RD
Mailing Address - Street 2:
Mailing Address - City:VALDERS
Mailing Address - State:WI
Mailing Address - Zip Code:54245-9582
Mailing Address - Country:US
Mailing Address - Phone:920-410-1656
Mailing Address - Fax:
Practice Address - Street 1:3509 DEWEY ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5813
Practice Address - Country:US
Practice Address - Phone:920-686-5731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8830392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer