Provider Demographics
NPI:1467094078
Name:OTTERBECK, JASON (CASAC-T)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:OTTERBECK
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-2516
Mailing Address - Country:US
Mailing Address - Phone:631-946-6060
Mailing Address - Fax:631-946-6063
Practice Address - Street 1:6 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2516
Practice Address - Country:US
Practice Address - Phone:631-946-6060
Practice Address - Fax:631-946-6063
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34592101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty