Provider Demographics
NPI:1639746936
Name:OTTERNESS, KATRIN BRIANNA
Entity Type:Individual
Prefix:
First Name:KATRIN
Middle Name:BRIANNA
Last Name:OTTERNESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3944 RANCH ROAD 620 S STE 201
Mailing Address - Street 2:
Mailing Address - City:BEE CAVE
Mailing Address - State:TX
Mailing Address - Zip Code:78738-7166
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3944 RANCH ROAD 620 S STE 201
Practice Address - Street 2:
Practice Address - City:BEE CAVE
Practice Address - State:TX
Practice Address - Zip Code:78738-7166
Practice Address - Country:US
Practice Address - Phone:512-593-5195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician