Provider Demographics
NPI:1477661981
Name:OTIS, MARK RAYMOND (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAYMOND
Last Name:OTIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 LBJ FREEWAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7619
Mailing Address - Country:US
Mailing Address - Phone:972-241-0674
Mailing Address - Fax:
Practice Address - Street 1:2925 LBJ FREEWAY
Practice Address - Street 2:SUITE 180
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7619
Practice Address - Country:US
Practice Address - Phone:972-241-0674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22147103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical