Provider Demographics
NPI:1699428995
Name:OTTESON, LUKAS WYATT
Entity type:Individual
Prefix:
First Name:LUKAS
Middle Name:WYATT
Last Name:OTTESON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7136 EAGLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-3046
Mailing Address - Country:US
Mailing Address - Phone:760-759-3865
Mailing Address - Fax:
Practice Address - Street 1:9015 MURRAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3675
Practice Address - Country:US
Practice Address - Phone:408-842-7138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health