Provider Demographics
NPI:1114049673
Name:OTTO, SHANNON JOEL (LMSW)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:JOEL
Last Name:OTTO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-4049
Mailing Address - Country:US
Mailing Address - Phone:575-390-1958
Mailing Address - Fax:
Practice Address - Street 1:220 4TH AVE
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2643
Practice Address - Country:US
Practice Address - Phone:575-445-2754
Practice Address - Fax:575-445-2225
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3133651041S0200X
NMM-058991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13829068Medicaid