Provider Demographics
NPI:1043579147
Name:OTTO, MICHAEL PAUL (PSYD, LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PAUL
Last Name:OTTO
Suffix:
Gender:M
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 MACUNGIE AVE
Mailing Address - Street 2:
Mailing Address - City:EMMAUS
Mailing Address - State:PA
Mailing Address - Zip Code:18049-1643
Mailing Address - Country:US
Mailing Address - Phone:610-762-5994
Mailing Address - Fax:
Practice Address - Street 1:1259 S CEDAR CREST BLVD STE 325
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103
Practice Address - Country:US
Practice Address - Phone:610-762-5994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-09
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005267101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional