Provider Demographics
NPI:1346952629
Name:CANTRELL, OTIS (MT-BC)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 N HILLSDALE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-4225
Mailing Address - Country:US
Mailing Address - Phone:765-621-9899
Mailing Address - Fax:
Practice Address - Street 1:335 N HILLSDALE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-4225
Practice Address - Country:US
Practice Address - Phone:765-621-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist