Provider Demographics
NPI:1568746188
Name:OTT, ANDREA DE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:DE
Last Name:OTT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:SOBEIDA
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:100 MELROSE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6277
Mailing Address - Country:US
Mailing Address - Phone:203-970-4738
Mailing Address - Fax:
Practice Address - Street 1:100 MELROSE AVE STE 103
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6277
Practice Address - Country:US
Practice Address - Phone:203-970-4738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT84-1863222Medicaid