Provider Demographics
NPI:1457309304
Name:OTTO, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL HOSPITAL
Mailing Address - Street 2:BOX 34
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09589
Mailing Address - Country:CU
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL BOX 34
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09589
Practice Address - Country:CU
Practice Address - Phone:01153-997-2650
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000068491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical