Provider Demographics
NPI:1639133531
Name:LOTT, JOHN III (ISW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LOTT
Suffix:III
Gender:M
Credentials:ISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S CENTRAL AVE
Mailing Address - Street 2:#16
Mailing Address - City:UMATILLA
Mailing Address - State:FL
Mailing Address - Zip Code:32784-9566
Mailing Address - Country:US
Mailing Address - Phone:352-315-7850
Mailing Address - Fax:352-360-6582
Practice Address - Street 1:2020 TALLEY RD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3426
Practice Address - Country:US
Practice Address - Phone:352-315-7850
Practice Address - Fax:352-360-6582
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW 30841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL765642400Medicaid