Provider Demographics
NPI:1114980307
Name:OTZENBERGER, JOHN H (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:OTZENBERGER
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 1:5100 LANSING DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-6030
Mailing Address - Country:US
Mailing Address - Phone:704-719-3974
Mailing Address - Fax:
Practice Address - Street 1:10508 PARK RD
Practice Address - Street 2:SUITE 130
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8405
Practice Address - Country:US
Practice Address - Phone:704-541-9080
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3099103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical