Provider Demographics
NPI:1619681251
Name:OTIS, EDMOND L
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:L
Last Name:OTIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 UNIVERSITY AVE STE 6-570
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-8810
Mailing Address - Country:US
Mailing Address - Phone:760-612-7029
Mailing Address - Fax:
Practice Address - Street 1:26449 BODEGA CT
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-2461
Practice Address - Country:US
Practice Address - Phone:760-612-7029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31194106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist