Provider Demographics
NPI:1851707574
Name:OTTO, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 982
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82073-0982
Mailing Address - Country:US
Mailing Address - Phone:307-630-4729
Mailing Address - Fax:307-632-3298
Practice Address - Street 1:1607 CAPITOL AVE FL THE2
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-630-4729
Practice Address - Fax:307-632-3298
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPCSW-583101Y00000X
WYLCSW-9831041C0700X
WY983101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPCSW-583OtherMENTAL HEALTH PROFESSIONS LICENSING BOARD
WYLCSW-983OtherSTATE LICENSE