Provider Demographics
NPI:1093065955
Name:OTTO, TRAVIS LEWELLEN (PSYD)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:LEWELLEN
Last Name:OTTO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 WILLET CT
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-8224
Mailing Address - Country:US
Mailing Address - Phone:813-361-4809
Mailing Address - Fax:
Practice Address - Street 1:2505 CROWDER LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6253
Practice Address - Country:US
Practice Address - Phone:813-361-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8595103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical