Provider Demographics
NPI:1790460491
Name:OTTWELL, TAYLOR (MA, PLPC)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:OTTWELL
Suffix:
Gender:F
Credentials:MA, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 HUBER PARK CT STE 203
Mailing Address - Street 2:
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-8683
Mailing Address - Country:US
Mailing Address - Phone:636-395-0513
Mailing Address - Fax:
Practice Address - Street 1:500 HUBER PARK CT STE 203
Practice Address - Street 2:
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-8683
Practice Address - Country:US
Practice Address - Phone:636-395-0513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023021563101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional