Provider Demographics
NPI:1396197851
Name:OTT, KEVIN (LCSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:OTT
Suffix:
Gender:M
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 60092
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-0092
Mailing Address - Country:US
Mailing Address - Phone:631-835-1100
Mailing Address - Fax:
Practice Address - Street 1:407 SHERMAN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-1873
Practice Address - Country:US
Practice Address - Phone:651-461-9026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0822401041C0700X
CA725121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical