Provider Demographics
NPI:1790296754
Name:OTTERSON, MARCE J (DPT)
Entity Type:Individual
Prefix:
First Name:MARCE
Middle Name:J
Last Name:OTTERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W BEATON DR STE 105
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2653
Mailing Address - Country:US
Mailing Address - Phone:701-205-4194
Mailing Address - Fax:701-540-9044
Practice Address - Street 1:102 W BEATON DR
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078
Practice Address - Country:US
Practice Address - Phone:701-205-4194
Practice Address - Fax:701-540-9044
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10948225100000X
ND2150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1460826Medicaid