Provider Demographics
NPI:1518163633
Name:OTTERNESS, NATASHA (SLP)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:OTTERNESS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 DIAMOND CV
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3669
Mailing Address - Country:US
Mailing Address - Phone:850-582-6495
Mailing Address - Fax:
Practice Address - Street 1:2900 CHARLEVOIX DR SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7086
Practice Address - Country:US
Practice Address - Phone:800-684-8049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4491235Z00000X
TX103129235Z00000X
FLSA7799235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist