Provider Demographics
NPI:1770853574
Name:OTU, THERESA N (LPC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:N
Last Name:OTU
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7252 91ST AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8253
Mailing Address - Country:US
Mailing Address - Phone:502-412-4564
Mailing Address - Fax:
Practice Address - Street 1:10117 74TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7533
Practice Address - Country:US
Practice Address - Phone:262-697-8268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5157-125101YP2500X
KYKY-1567101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional