Provider Demographics
NPI:1508822321
Name:OTIS, H GRAY (PHD)
Entity Type:Individual
Prefix:
First Name:H
Middle Name:GRAY
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 1:3437 BEAR CANYON LN
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILLS
Mailing Address - State:UT
Mailing Address - Zip Code:84062-8014
Mailing Address - Country:US
Mailing Address - Phone:801-885-8585
Mailing Address - Fax:
Practice Address - Street 1:8817 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9271
Practice Address - Country:US
Practice Address - Phone:801-748-2270
Practice Address - Fax:801-748-2271
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5740241-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional