Provider Demographics
NPI:1225011869
Name:OTT, MELODY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELODY
Middle Name:
Last Name:OTT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 SOUTHPARK CIR E
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5137
Mailing Address - Country:US
Mailing Address - Phone:904-797-5680
Mailing Address - Fax:904-797-5681
Practice Address - Street 1:248 SOUTHPARK CIR E
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5137
Practice Address - Country:US
Practice Address - Phone:904-797-5680
Practice Address - Fax:904-797-5681
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW66181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ010NOtherBLUE CROSS BLUE SHIELD
FLZ010NOtherBLUE CROSS BLUE SHIELD