Provider Demographics
NPI:1467942490
Name:OTIS, DONNA BETH (PHD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:BETH
Last Name:OTIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 HIGH ROCK TER
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-2654
Mailing Address - Country:US
Mailing Address - Phone:617-233-2625
Mailing Address - Fax:
Practice Address - Street 1:648 BEACON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-2012
Practice Address - Country:US
Practice Address - Phone:617-353-9610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8518103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical