Provider Demographics
NPI:1326597006
Name:OTT, GRACE BINGHAM (LCSW)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:BINGHAM
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:PO BOX 448
Mailing Address - Street 2:
Mailing Address - City:SPRUCE HEAD
Mailing Address - State:ME
Mailing Address - Zip Code:04859-0448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 ANCHOR DR STE 201
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-3845
Practice Address - Country:US
Practice Address - Phone:207-301-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC159521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical