Provider Demographics
NPI:1275046583
Name:OTT, CASSONDRA
Entity Type:Individual
Prefix:
First Name:CASSONDRA
Middle Name:
Last Name:OTT
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 1:2940 CHAPEL VALLEY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1320 MENDOTA ST STE 120
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-1060
Practice Address - Country:US
Practice Address - Phone:608-280-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1275046583Medicaid