Provider Demographics
NPI:1942365887
Name:OTTERSON, TROY DAVID (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:DAVID
Last Name:OTTERSON
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 W SUPERIOR ST STE A
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1608
Mailing Address - Country:US
Mailing Address - Phone:218-740-3061
Mailing Address - Fax:218-740-3044
Practice Address - Street 1:324 W SUPERIOR ST
Practice Address - Street 2:STE 600
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1701
Practice Address - Country:US
Practice Address - Phone:218-723-8153
Practice Address - Fax:218-722-7625
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN182011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical