Provider Demographics
NPI:1790065779
Name:OTALLAH, JOHN A (ED S)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:OTALLAH
Suffix:
Gender:M
Credentials:ED S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17158 LAKEMONT DR
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-7910
Mailing Address - Country:US
Mailing Address - Phone:540-825-1462
Mailing Address - Fax:
Practice Address - Street 1:14115 LOVERS LN
Practice Address - Street 2:SUITE 56
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-4157
Practice Address - Country:US
Practice Address - Phone:540-308-3857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0803000022103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool