Provider Demographics
NPI:1043861032
Name:OTTO, SAMANTHA GAGE (LPC, NCC, CAADC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GAGE
Last Name:OTTO
Suffix:
Gender:F
Credentials:LPC, NCC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-3912
Mailing Address - Country:US
Mailing Address - Phone:609-477-2652
Mailing Address - Fax:
Practice Address - Street 1:806 VETERANS HWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007-2507
Practice Address - Country:US
Practice Address - Phone:267-689-7875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-22
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011740101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor