Provider Demographics
NPI:1811314305
Name:OTTEN, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:OTTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5065 GAUSE RD
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:OH
Mailing Address - Zip Code:45828-9783
Mailing Address - Country:US
Mailing Address - Phone:419-942-0008
Mailing Address - Fax:
Practice Address - Street 1:400 BUCKEYE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:OH
Practice Address - Zip Code:45882-9267
Practice Address - Country:US
Practice Address - Phone:419-363-3045
Practice Address - Fax:419-363-2598
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.6652235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist