Provider Demographics
NPI:1710035894
Name:OTTOBONI, BRITTA TIDEMAND (ATC, L-MT)
Entity Type:Individual
Prefix:MRS
First Name:BRITTA
Middle Name:TIDEMAND
Last Name:OTTOBONI
Suffix:
Gender:F
Credentials:ATC, L-MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-1275
Mailing Address - Country:US
Mailing Address - Phone:248-613-2279
Mailing Address - Fax:
Practice Address - Street 1:4525 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48324-1275
Practice Address - Country:US
Practice Address - Phone:248-681-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist