Provider Demographics
NPI:1356840888
Name:OTTO, PAMELA SUE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:OTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:SUE
Other - Last Name:HAMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10850 S US HIGHWAY 1 STE 2
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-6407
Mailing Address - Country:US
Mailing Address - Phone:772-463-0444
Mailing Address - Fax:
Practice Address - Street 1:10850 S US HIGHWAY 1 STE 2
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-6407
Practice Address - Country:US
Practice Address - Phone:772-463-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-10
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
1-20-45220103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician