Provider Demographics
NPI:1073095832
Name:OTIS, BARBARA
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:OTIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8211 MARIGOLD AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2556
Mailing Address - Country:US
Mailing Address - Phone:813-469-9195
Mailing Address - Fax:
Practice Address - Street 1:1413 TECH BLVD STE 122
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-7822
Practice Address - Country:US
Practice Address - Phone:813-305-2867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-117118106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician