Provider Demographics
NPI:1720894074
Name:OTL OUTPATIENT SERVICES LLC
Entity type:Organization
Organization Name:OTL OUTPATIENT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-520-4600
Mailing Address - Street 1:9201 ARBORETUM PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-5407
Mailing Address - Country:US
Mailing Address - Phone:804-520-4600
Mailing Address - Fax:833-525-0063
Practice Address - Street 1:9201 ARBORETUM PKWY STE 300
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-5407
Practice Address - Country:US
Practice Address - Phone:804-520-4600
Practice Address - Fax:833-525-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty