Provider Demographics
NPI:1194377127
Name:OTTENS, LAURIE
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:OTTENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 W ALMA ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2102
Mailing Address - Country:US
Mailing Address - Phone:530-859-0628
Mailing Address - Fax:
Practice Address - Street 1:445 PARK ST
Practice Address - Street 2:
Practice Address - City:WEED
Practice Address - State:CA
Practice Address - Zip Code:96094-2332
Practice Address - Country:US
Practice Address - Phone:530-938-4429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist