Provider Demographics
NPI:1891377172
Name:OTWELL, BRIANNA LEIGH (LPC INTERN)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:LEIGH
Last Name:OTWELL
Suffix:
Gender:F
Credentials:LPC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4538 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2740
Mailing Address - Country:US
Mailing Address - Phone:903-306-1134
Mailing Address - Fax:
Practice Address - Street 1:4538 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2740
Practice Address - Country:US
Practice Address - Phone:903-306-1134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83534101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor