Provider Demographics
NPI:1821476573
Name:OTTMAN, TRACIE (MA, LPCA)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:OTTMAN
Suffix:
Gender:F
Credentials:MA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 FAIRWAY DR
Mailing Address - Street 2:STE 102
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1121 HAMPSHIRE LN STE 100
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-4306
Practice Address - Country:US
Practice Address - Phone:469-367-6785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
TX90507103TC1900X
NCA15044101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor