Provider Demographics
NPI:1710605167
Name:SYSTEMIC PSYCHOTHERAPY LCSW, PLLC
Entity Type:Organization
Organization Name:SYSTEMIC PSYCHOTHERAPY LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-970-4738
Mailing Address - Street 1:420 WESTCHESTER AVE # 2B
Mailing Address - Street 2:
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-3600
Mailing Address - Country:US
Mailing Address - Phone:203-970-4738
Mailing Address - Fax:
Practice Address - Street 1:420 WESTCHESTER AVE # 2B
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-3600
Practice Address - Country:US
Practice Address - Phone:203-970-4738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SYSTEMIC PSYCHOTHERAPY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06296166Medicaid