Provider Demographics
NPI:1053465989
Name:OTTO, KIMBERLYN J (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLYN
Middle Name:J
Last Name:OTTO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIMBERLYN
Other - Middle Name:J
Other - Last Name:LEGGETT-OTTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 UNION ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-1175
Mailing Address - Country:US
Mailing Address - Phone:608-882-5613
Mailing Address - Fax:
Practice Address - Street 1:300 UNION ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1175
Practice Address - Country:US
Practice Address - Phone:608-882-5613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39692500Medicaid
WI39692500Medicaid