Provider Demographics
NPI:1881188423
Name:OTTO, ANDI KATELYN (COTA)
Entity Type:Individual
Prefix:MISS
First Name:ANDI
Middle Name:KATELYN
Last Name:OTTO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4578 LEROY PKWY
Mailing Address - Street 2:
Mailing Address - City:ELM MOTT
Mailing Address - State:TX
Mailing Address - Zip Code:76640-3551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5400 LAUREL LAKE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2835
Practice Address - Country:US
Practice Address - Phone:254-774-4644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214-510224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant