Provider Demographics
NPI:1851647671
Name:OTTO, ROBERT WILLIAM (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:OTTO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 NE 31ST ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6723
Mailing Address - Country:US
Mailing Address - Phone:561-350-8789
Mailing Address - Fax:561-491-6563
Practice Address - Street 1:2400 YAMATO RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-8403
Practice Address - Country:US
Practice Address - Phone:561-350-8789
Practice Address - Fax:561-491-6563
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2707106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist