Provider Demographics
NPI:1922255389
Name:OTTO, BRANDY NICOLE (MHPP)
Entity Type:Individual
Prefix:MS
First Name:BRANDY
Middle Name:NICOLE
Last Name:OTTO
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5537 BLEAUX AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-0737
Mailing Address - Country:US
Mailing Address - Phone:479-872-5580
Mailing Address - Fax:479-872-5581
Practice Address - Street 1:1910 MOCKINGBIRD LN
Practice Address - Street 2:STE B & C
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5806
Practice Address - Country:US
Practice Address - Phone:870-240-0671
Practice Address - Fax:870-240-0514
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor