Provider Demographics
NPI:1508317926
Name:OTTEN, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:OTTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:DECLERCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:608 E PREDA DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2025
Mailing Address - Country:US
Mailing Address - Phone:248-240-0546
Mailing Address - Fax:
Practice Address - Street 1:608 E PREDA DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2025
Practice Address - Country:US
Practice Address - Phone:248-240-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010928601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical