Provider Demographics
NPI:1073603437
Name:OTTO, TRACI J (MS)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:J
Last Name:OTTO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7474 SOUTH CAMINO DE OESTE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85757
Mailing Address - Country:US
Mailing Address - Phone:520-879-6077
Mailing Address - Fax:
Practice Address - Street 1:7474 SOUTH CAMINO DE OESTE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85757
Practice Address - Country:US
Practice Address - Phone:520-879-6077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE905101YA0400X
AZLISAC-15036101YA0400X
NE3011101YM0800X
NE436101YM0800X
AZLPC-15542101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE85632OtherBCBS PIN
NE250405OtherMIDLANDS CHOICE PIN
NE743005000Medicaid
NE10025378400Medicaid