Provider Demographics
NPI:1134329238
Name:LOCKETT,, OTIS JR (MS,LPC, CSAC, ICS,)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:
Last Name:LOCKETT,
Suffix:JR
Gender:M
Credentials:MS,LPC, CSAC, ICS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 W WELLS ST
Mailing Address - Street 2:SUITE 214
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1866
Mailing Address - Country:US
Mailing Address - Phone:414-839-8994
Mailing Address - Fax:414-223-3817
Practice Address - Street 1:230 W WELLS ST
Practice Address - Street 2:SUITE 214
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-1866
Practice Address - Country:US
Practice Address - Phone:414-839-8994
Practice Address - Fax:414-291-6407
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1661101YA0400X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39394200Medicaid