Provider Demographics
NPI:1003270810
Name:OTTO, ANGELA (LAC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 N MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3095
Mailing Address - Country:US
Mailing Address - Phone:406-257-6240
Mailing Address - Fax:406-752-0534
Practice Address - Street 1:431 1ST AVE W
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4959
Practice Address - Country:US
Practice Address - Phone:406-607-4971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT16845101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)