Provider Demographics
NPI:1295192722
Name:MANN, OTIS H (LPC)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:H
Last Name:MANN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:JOSHUA
Mailing Address - State:TX
Mailing Address - Zip Code:76058-1090
Mailing Address - Country:US
Mailing Address - Phone:817-558-2988
Mailing Address - Fax:817-558-3157
Practice Address - Street 1:214 N CADDO ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76031-4904
Practice Address - Country:US
Practice Address - Phone:817-558-2988
Practice Address - Fax:817-558-3157
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67630101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health