Provider Demographics
NPI:1922686724
Name:OTT, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:OTT
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 1:8272 FOREST LN
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7721
Mailing Address - Country:US
Mailing Address - Phone:231-632-5458
Mailing Address - Fax:231-935-1929
Practice Address - Street 1:8272 FOREST LN
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7721
Practice Address - Country:US
Practice Address - Phone:231-632-5458
Practice Address - Fax:231-632-5458
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010874311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical