Provider Demographics
NPI:1962087502
Name:OTIS, ALISON (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:
Last Name:OTIS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:ALISON
Other - Middle Name:
Other - Last Name:MATZKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1906 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-6006
Mailing Address - Country:US
Mailing Address - Phone:773-419-6014
Mailing Address - Fax:
Practice Address - Street 1:4400 E MICHIGAN BLVD
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3189
Practice Address - Country:US
Practice Address - Phone:219-879-6115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005940A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist