Provider Demographics
NPI:1043751787
Name:OTA, AMY SUZANNE (LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:SUZANNE
Last Name:OTA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8026 WHITWORTH LN
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-3416
Mailing Address - Country:US
Mailing Address - Phone:512-944-2751
Mailing Address - Fax:
Practice Address - Street 1:595 ROUND ROCK WEST DR STE 104
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-5028
Practice Address - Country:US
Practice Address - Phone:512-815-3723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72064101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional