Provider Demographics
NPI:1609423177
Name:OTT, MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:OTT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:12250 DEER FLAT RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-9118
Mailing Address - Country:US
Mailing Address - Phone:208-949-5016
Mailing Address - Fax:
Practice Address - Street 1:12250 DEER FLAT RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-9118
Practice Address - Country:US
Practice Address - Phone:208-949-5016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-2554235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist