Provider Demographics
NPI:1912368077
Name:OTTENS, BRADFORD A
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:A
Last Name:OTTENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 W ANDREW JOHNSON HWY
Mailing Address - Street 2:SUITE E
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3276
Mailing Address - Country:US
Mailing Address - Phone:423-200-3510
Mailing Address - Fax:
Practice Address - Street 1:2412 W ANDREW JOHNSON HWY
Practice Address - Street 2:SUITE E
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3276
Practice Address - Country:US
Practice Address - Phone:423-200-3510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000017907171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator