Provider Demographics
NPI:1598937427
Name:OTTENSMEIER, KELLY ANN (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:OTTENSMEIER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-3015
Mailing Address - Country:US
Mailing Address - Phone:618-346-6641
Mailing Address - Fax:618-346-6638
Practice Address - Street 1:106 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-3015
Practice Address - Country:US
Practice Address - Phone:618-346-6641
Practice Address - Fax:618-346-6638
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006663101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health