Provider Demographics
NPI:1235451279
Name:OTT, ELIZABETH KARG (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:KARG
Last Name:OTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 SEQUIOA ST.
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-8907
Mailing Address - Country:US
Mailing Address - Phone:239-560-7503
Mailing Address - Fax:
Practice Address - Street 1:677 SEQUIOA ST.
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-8907
Practice Address - Country:US
Practice Address - Phone:239-560-7503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0579103TC0700X
OHE-0001224101Y00000X
OH2033103T00000X
OH0579103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist