Provider Demographics
NPI:1568116556
Name:OTTO, KRYSTLE (AMFT)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:KRYSTLE
Other - Middle Name:E
Other - Last Name:NEWTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AMFT
Mailing Address - Street 1:1131 WILLIAMS TER
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36854-5333
Mailing Address - Country:US
Mailing Address - Phone:706-590-3819
Mailing Address - Fax:
Practice Address - Street 1:2002 35TH ST STE D
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3118
Practice Address - Country:US
Practice Address - Phone:334-710-9124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALL616106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist