Provider Demographics
NPI:1376183731
Name:OTIS, GINA (LMT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:OTIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 IMPALA DR
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-1505
Mailing Address - Country:US
Mailing Address - Phone:631-445-9937
Mailing Address - Fax:
Practice Address - Street 1:196 N BELLE MEAD RD STE 3
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3477
Practice Address - Country:US
Practice Address - Phone:631-445-9937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010973225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty