Provider Demographics
NPI:1891813465
Name:OTTO, TINA SUE (LPC, CADC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:SUE
Last Name:OTTO
Suffix:
Gender:F
Credentials:LPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 300C
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:IL
Mailing Address - Zip Code:62080-9402
Mailing Address - Country:US
Mailing Address - Phone:618-423-9590
Mailing Address - Fax:
Practice Address - Street 1:421 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-2214
Practice Address - Country:US
Practice Address - Phone:618-283-4229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17890101YA0400X
IL178.006052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health